PTA 160FUNDAMENTALS OF

TREATMENT III

Day 6

Lesson Objectives List the characteristics of a wound needed to determine

wound classification. Define terminology associated with wound care. Practice documentation associated with wound

examination. List the different types of ulcers. Identify risk factors associated with pressure ulcers. Identify the stage of a pressure ulcer based on wound

characteristics. Discuss characteristics of vascular ulcers. Demonstrate understanding of diabetic foot ulcers. Discuss characteristics of malignant wounds.

Wound Classification

Wound Age

Wound Depth

Wound Color

Wound ClassificationWound Age

Acute Chronic

New or relatively new wound

Occurs suddenly Healing progresses in a

timely, predictable manner

Typically heals by primary intention

Examples: surgical and traumatic wounds

May develop over time Healing has slowed or

stopped Typically heals by

secondary intention Examples: pressure,

vascular and diabetic ulcers

Wound ClassificationWound Depth

Partial thickness woundInvolves only epidermis or epidermis and

part of the dermisDoes not extend through the dermis

Full thickness woundExtends through the dermis into tissues

beneathMay expose adipose tissue, muscle or bone

Wound ClassificationWound Color Red-Yellow-Black Classification System

Red wounds: indicate normal healing○ Red because of granulation tissue

Yellow wounds: fibrin left from healing process appears as yellow slough or dead tissue on wound base○ Slough, or soft necrotic tissue, serves as a medium

for bacteria growthBlack wounds: indicates necrosis

○ Eschar ○ Cannot accurately assess a wound covered in

eschar

Wound ColorWound Color Management Technique

Red • Cover wound, maintain moist environment, and protect from trauma

Yellow • Clean wound and remove yellow layer• Cover with moisture-retentive dressing

Black • Debridement as ordered• Don’t debride wounds with inadequate blood supply

Classifying multicolor wounds:• classify according to the least healthy color

Wound Terminology Abrasion: occurs from a scraping away of

the surface layers of skin, often result of trauma

Contusion: skin is not broken; characterized by pain, swelling and discoloration (bruise)

Hematoma: swelling or mass of blood, usually caused by a break in a blood vessel

Laceration: wound or irregular tear of tissues often assoc. with trauma (cut)

Wound Terminology

Penetrating wound: wound that enters into the interior of an organ or cavity

Puncture: a wound made by a sharp pointed instrument or objet by penetrating through the skin into underlying tissues

Wound Terminology

Granulation: beefy red, bumpy, shiny tissue in the base of an ulcer

Epithelial tissue: pale or dark pink skin, first appears at wound borders

Slough: soft, yellow necrotic tissue Eschar: thick, hard, leathery black

tissue; indicates dry, necrotic tissue Macerated tissue: indicates too much

water, white at edges

Wound Terminology

Drainage (Exudate) Descriptions Serous: clear, light color with thin, watery

consistency Sanguineous: red with thin, watery consistency;

indicates new vessel growth or disruption of blood vessels

Serosanguineous: light red or pink with thin, watery consistency; can be seen in healthy wound

Purulent: creamy yellow, green, white or tan; thick and opaque

Types of ulcers

Pressure ulcers Vascular ulcers

Arterial ulcersVenous ulcersLymphatic ulcers

Neuropathic ulcersDiabetic ulcers

Malignant wounds

Pressure ulcers

Causes Occur when pressure compresses soft

tissue over bony prominences Friction and shear contribute to

development of pressure ulcers

Pressure Ulcer

Risk Factors Advanced Age Immobile Incontinence Infection Low blood pressure Malnutrition

Pressure Ulcers

Prevention Pressure relief

Positioning, air mattress Reduce friction and shear Maximize nutritional status Control chronic illness (such as

diabetes) Manage moisture associated with

incontinence

Pressure Ulcers

Assessment Length X width

Measure the greatest length (head to toe) and the greatest width (side to side). Always use a cm ruler

Exudate amount Estimate the draining

present after removing dressing and before applying any ointment

Classify as none, light, moderate or heavy

Assessment cont. Tissue type

Type of tissue in wound bed

Describe as necrotic, slough, granulation, epithelial, or closed

Pressure UlcersAssessment cont.

Staging: National Pressure Ulcer Advisory Panel (NPAUP)

Stage I: intact skin, but color differs from surrounding area; changes in skin temperature, tissue consistency and sensation

Stage II: partial thickness loss of epidermis and/or dermis; shallow, open; may also present as a blister or abrasion

Pressure UlcersStaging cont. Stage III: Full thickness tissue loss;

subcutaneous fat may be visible; deep crater, with or without undermining or tunneling into adjacent tissue

Stage IV: full thickness tissue loss with exposed bone, tendon, or muscle; undermining and tunneling are common

Pressure Ulcers

Treatment Patient education Pressure relief Manage moisture Nutritional assessment and support Proper wound care

Vascular UlcersType of Ulcer

Typical Location Clinical Findings

Venous •Anywhere ankle to midcalf•Most common on medial aspect of ankle above malleolus

• irregular shape• shallow; lots of exudate• mild to moderate pain• normal pedal pulses• edema•Normal skin temperature

Arterial • lower 1/3 of leg• distal toes• dorsal foot• over bony prominences

• smooth edges, well defined• deep• severe pain• diminished or absent pulses• dependent rubor• skin is thin and shiny; hair loss; yellow nails

Lymphatic • arms and legs• most common at ankle

• shallow ulcer bed• oozing, moist or blistered• skin around wound is firm, fibrotic• Edema; cellulitis

Vascular Ulcers

Venous Ulcers – Causes and S&S Wounds result from venous insufficiency

Incompentent valvesInadequate calf muscle function

Pitting edema is common Pt c/o itching, fatigue, aching, and heaviness

in involved limbs

Vascular Ulcers

Venous Ulcers – Continued Eczema is commons in patients with

recurrent ulcers Skin changes including hemosiderosis (inc

localized iron stores) and lipodermatosclerosis (extemely smooth skin that turns brown and becomes tight and painful from inflammation of fatty tissue)

Vascular Ulcers

Venous Ulcers – Assessment Must determine if patient also has

arterial insufficiency Measure and monitor edema Classify as partial thickness or full

thickness wound

Vascular Ulcers

Arterial Ulcers – Causes Result from tissue ischemia caused by

insufficient blood flow to an area Causes

Arterial stenosisObstruction (from thrombosis, emboli,

atherosclerosis, vasculitis or Raynaud’s phenomenon

Vascular Ulcers

Arterial Ulcers – S&S Dependent rubor Pain in legs and feet Pale, shiny skin Faint or absent pulses Ulcers on dorsum of foot, distal toes,

lateral malleolus

Vascular Ulcers

Arterial Ulcers – Assessment Ankle Brachial Index (ABI)

A test to examine the vascular system. A normal resting ankle-brachial index is 1.0 to 1.4. This means that your blood pressure at your ankle is the same or greater than the pressure at your arm, and suggests that you do not have significant narrowing or blockage of blood flow. Abnormal is .9 or less

Vascular Ulcers

Arterial Ulcers – Assessment

Medical diagnostic tests are often necessary to determine if there is adequate blood flow to the LE to support healing

Vascular Ulcers

Lymphatic Ulcers – Causes and S&S Result from injury to a body part afflicted with

lymphedemaPressure on capillariesSkin folds from massive swellingTraumatic injury or pressure

Ulcers are typically shallow with large amounts of moisture

No pitting edema Lots of swelling Thickened skin

Vascular Ulcers

Lymphatic Ulcers – Assessment Patient history of damage or injury to

lymphatic system Inspection Palpation Girth measurements No special tests are usually needed

Vascular Ulcers TreatmentType of Ulcer

Treatment Goals Therapies & procedures

Wound care

Venous • edema control• manage underlying venous disease• provide appropriate wound care

• elevate limb• compression bandages• compression stockings• unna’s boot

• occlusive dressings• apply growth factors as ordered

Arterial • reestablish blood flow• provide appropriate wound care

• arterial bypass• angioplasty

• keep wound dry and protected from pressure• never soak arterial ulcers

Lymphatic • reduce edema• prevent infection• provide appropriate wound care

• limb elevation• compression therapy• comprehensive decongestive therapy

• follow guidelines for venous ulcer care• choose dressings that can manage large amounts of exudate while protecting surrounding skin

Neuropathic UlcersCauses diabetes is most common cause

S & S Located on weightbearing surfaces of the foot Could have sensory, motor and/or autonomic

neuropathy Calluses Induration is common Erythema Skin fissures Dry, scaly skin Pedal pulses diminished or absent Usually good granulation with little to no drainage

Neuropathic Ulcers

Prevention Control diabetes

Patient education in regards to maintaining careful glycemic control

Foot hygieneInspect feet daily for injury or pressure areasWash feed with mild soap, dry between toesDon’t go barefootTake extreme caution with cutting toenails,

best to see a podiatrist

Neuropathic Ulcers

Prevention cont. Choosing socks

Wear natural fiber socksChoose socks that take perspiration away from

skinUse diabetic socks for shear and friction control

Choosing shoesWear shoes that fit wellBreak in new shoesInspect shoes prior to putting on

Neuropathic Ulcers

Assessment Semmes-Weinstein test

Uses monofilaments to check protective sensation in feet

Wagner Ulcer Grade classificationUsed to evaluate diabetic ulcersLow scores represent less complex ulcers

Wagner Ulcer Grade ClassificationGrade Characteristics

0 • pre-ulcerous lesion• healed ulcer• presence of bony deformity

1 • superficial ulcer without subcutaneous tissue involvement

2 • deep ulcer with penetration through subcutaneous tissue; may involve bone, tendon, or muscle

3 • deep ulcer, abscess or osteomyelitis

4 • gangrene of a digit

5 • gangrene of foot requiring amputation

Neuropathic Ulcers

Treatment Relieve pressure on area of wound Surgical referral for bony deformities Callus debridement Appropriate wound care Use of growth factors as ordered

Malignant Wounds

Causes Develop from primary or metastatic

tumor that infiltrates the epidermis Commonly occur in patients with breast

cancer Also in patients with untreated skin

cancer

Malignant Wounds

Characteristics Grow rapidly Often invade surrounding tissues/organs Sinus tracts and fistulas are common Cauliflower like appearance Fragile blood vessels Large amounts of necrotic tissue

Malignant Wounds

Complications Odor Bleeding Exudate Pruritus (itching) Pain

Malignant Wounds

Treatment Control exudate and bleeding Use dressings to minimize odor Pain management

SummaryReview Objectives• List the characteristics of a wound needed to

determine wound classification.• Define terminology associated with wound care.• Practice documentation associated with wound

examination.• List the different types of ulcers.• Identify risk factors associated with pressure ulcers.• Identify the stage of a pressure ulcer based on wound

characteristics.• Discuss characteristics of vascular ulcers.• Demonstrate understanding of diabetic foot ulcers.• Discuss characteristics of malignant wounds.

Questions

Documentation Activity