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Wounds- All Types

Arterial Ulcer Lateral lower leg. Smooth edges. Deep. No drainage. Painful. Pallor on elevation, decreased pedal pulse
Venous Ulcer Medial lower leg. Shallow. Irregular edges. More exudate. Granulation present. Less painful, comfortable with legs elevated, pain with feet in dependent pos. Signs: edema, dermatitis, cyanosis in dependent pos. Pulse present.
Neuropathic Ulcer Not painful. Lack protective sensation. Location: WB areas. Healing impaired. 2.5-3 = Normal. 3-5 = decreased LT. 5.07 = protective sensation (monofilament). Test 1/3/5 MT head
Pressure Ulcer Stage 1 Non-blanchable redness
Pressure Ulcer Stage 2 Partial thickness loss of dermis. Looks like shallow, open ulcer with red wound bed. Ex: skin tear, serum filled blister
Pressure Ulcer Stage 3 Full thickness loss of dermis, subcutaneous fat may be visible, muscle not visible
Pressure Ulcer Stage 4 Exposed bone or tendon
Wagner Stage 0 No open lesion
Wagner Stage 1 Superficial ulcer, not involving subcutaneous tissue
Wagner Stage 2 Deep ulcer, through subcutaneous tissue, may expose bone
Wagner Stage 3 Deep ulcer with osteitis, abcess
Wagner Stage 4 Gangrene of Digit
Wagner Stage 5 Gangrene of foot, req disarticulation
Superficial Wound Epidermis intact ie sunburn
Partial thickness wound Through epidermis, dermis intact (abrasion, blister)
Full thickness Through dermis, into subcutaneous fat (requires secondary intention)
Subcutaneous Involves fat, muscle, bone
Primary intention Smooth edges reapproximated with sutures
Secondary intention Let wound close on its own
Tertiary intention AKA delayed primary. Wound temporarily left open, closed with sutures later
Created by: wooyeah