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