integ4 ulcers
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Pressure Ulcer | show 🗑
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show | High risk areas for pressure ulcers include the occiput, heels, greater trochanters, ischial tuberosities, sacrum, and epicondyles of the elbow
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show | Impaired cognition, poor nutrition, altered sensation, incontinence, decreased lean body mass, and infection contribute to the development of a pressure ulcer
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The integumentary system (or skin) | show 🗑
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Each layer is stratified | show 🗑
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The dermis | show 🗑
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show | is avascular and consists of the outermost layer of skin.
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prominences Supine: | show 🗑
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prominences Prone: | show 🗑
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show | Ears, lateral portion of acromion process, lateral head of humerus, lateral epicondyle of humerus, greater trochanter, head of fibula, lateral malleolus, medial malleolus
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show | Spine of the scapula, vertebral spinous processes, ischial tuberosities
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show | An observable pressure related alteration of intact skin whose indicators as compared to an adjacent or opposite area on the body may include changes in skin color, skin temperature, skin stiffness or sensation.
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Stage II | show 🗑
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show | A full-thickness skin loss that involves damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining adjacent tissue.
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show | A full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule).
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show | secondary to ischemia from inadequate circulation of oxygenated blood often due to complicating factors such as atherosclerosis
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show | secondary to inadequate functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration.
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Pressure ulcers, often called decubitus ulcers, | show 🗑
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Factors contributing to pressure ulcers include | show 🗑
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show | usually associated with a combination of ischemia and neuropathy
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show | diabetes. Neuropathic ulcers are frequently found on the plantar surface of the foot, often beneath the metatarsal heads. neuropathic ulcers The wound is typically well defined by a prominent callus rim.
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show | The wound has good granulation tissue and little or no drainage. Patients rarely report pain with neuropathic ulcers in part due to altered sensation.
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neuropathic ulcers | show 🗑
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neuropathic ulcers | show 🗑
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Factors Influencing Wound Healing | show 🗑
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Factors Influencing Wound Healing Age: | show 🗑
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show | Compromised medical status such as cardiovascular disease may significantly delay healing. This often results secondary to diminished oxygen and nutrients at the cellular level.
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show | An infected wound will impact essential activity associated with wound healing including fibroblast activity, collagen synthesis, and phagocytosis.
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show | Regular physical activity results in increased circulation that enhances wound healing. Lifestyle choices such as smoking negatively impacts wound healing by limiting the blood’s oxygen carrying capacity.
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show | There are a variety of pharmacological agents that can negatively impact wound healing. Medications falling into this category include steroids, anti-inflammatory drugs, heparin, antineoplastic agents, and oral contraceptives. Undesirable physiologic effe
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show | An abrasion is a wound that occurs from the scraping away of the surface layers of the skin, often as a result of trauma.
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Contusion: | show 🗑
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Hematoma: | show 🗑
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show | A laceration is a wound or irregular tear of tissues that is often associated with trauma.
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show | A penetrating wound is a wound that enters into the interior of an organ or cavity.
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show | A puncture is a wound that is made by a sharp pointed instrument or object by penetrating through the skin into underlying tissues.
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show | An ulcer is a lesion on the surface of the skin or the surface of a mucous membrane, produced by the sloughing of inflammatory, necrotic tissue.
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show | Pink granulation tissue
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show | Protect wound; maintain moist environment
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show | Moist yellow slough
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Red-Yellow-Black System Goals Yellow | show 🗑
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Red-Yellow-Black System Description Black | show 🗑
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show | Debride necrotic tissue
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Arterial Ulcers | show 🗑
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Arterial Ulcers | show 🗑
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Arterial Ulcers | show 🗑
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show | Diminished or absent
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show | Normal
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show | Decreased
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Venous Ulcers | show 🗑
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show | Irregular shape; shallow
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Venous Ulcers pedal pulses | show 🗑
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Venous Ulcers | show 🗑
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Venous Ulcers edema | show 🗑
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Arterial Ulcers Leg elevation | show 🗑
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Arterial Ulcers tissue changes | show 🗑
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Venous Ulcers Leg elevation | show 🗑
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Venous Ulcers tissue changes | show 🗑
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