Question | Answer |
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 |