Type of Wounds

what are 4 types of WOUNDS

1. pressure ulcers

2. arterial wounds

3. venous wounds

4. neuropathic ulcers

pressure ulcers

- Location: over bones (heels, sacrum, occiput, ischial tuberosity, greater trochanter)

- Ankle Brachial Index (ABI): normal (1.0-1.3)

- Pulse: normal

- Pain: variable

- Wound Shape: circular, triangular

- Wound Size: variable

- Wound Edge: variable (symmetrical: greater trochanter; irregular: coccyx)

- Wound Depth: variable

- Wound Bed + Appearance: variable (depends on depth)

- Edema: minimal

- Staining: absent

- Exudate/Drainage: variable (based on depth)

what is the location of PRESSURE ULCERS

over boney prominences

what are 5 common BONEY PROMINENCES where PRESSURE ULCERS are commonly located

1. heels

2. sacrum

3. occiput

4. ischial tuberosity

5. greater trochanter

what is the Ankle Brachial Index (ABI) of PRESSURE ULCERS

normal: 1.0-1.3

what is the pulse of PRESSURE ULCERS

normal

what is the pain of PRESSURE ULCERS

variable

what is the wound size of PRESSURE ULCERS

variable

what are the 2 wound shapes of PRESSURE ULCERS

1. circular

2. triangular

what is the wound edge of PRESSURE ULCERS

variable

(symmetrical: greater trochanter; irregular: coccyx)

what is the wound depth of PRESSURE ULCERS

variable

what is the wound bed + appearance of PRESSURE ULCERS

variable (depends on depth)

what is the edema of PRESSURE ULCERS

minimal

is the staining ABSENT/PRESENT with PRESSURE ULCERS

absent

what is the exudate/drainage of PRESSURE ULCERS

variable (based on depth)

arterial wounds

- Locations: distal lower 1/3 leg, lateral malleolus, foot dorsum, toes

- Ankle Brachial Index (ABI):

1. 0.6-0.8: borderline perfusion, intermittent claudication; pain w/ activity

2. ≤ 0.5: severe ischemia; pain at rest

3. ≤ 0.4: critical limb ischemia

- Pulse: absent (distal to wound)

- Pain: + to ++

- Wound Size: small

- Wound Shape: circular, punched out look

- Wound Edge: cliff/stair step

- Wound Depth: shallow to deep

- Wound Bed + Appearance: pale, dry, eschar (2 degree decreased circulation)

- Edema: minimal (localized)

- Staining: absent

- Exudate/Drainage: minimal

what are 4 locations where ARTERIAL WOUNDS are often located

1. distal lower 1/3 leg

2. lateral malleolus

3. foot dorsum

4. toes

what are the 3 Ankle Brachial Indexes associated with ARTERIAL WOUNDS

1. 0.6-0.8

2. ≤0.5

3. ≤0.4

what does an 0.6-0.8 ABI indicate

borderline perfusion, intermittent claudication

- pain w/ activity

what does a ≤0.5 ABI indicate

severe ischemia

- pain at rest

what does a ≤0.4 ABI indicate

critical limb ischemia

what is the pulse of ARTERIAL WOUNDS

absent

what is the pain of ARTERIAL WOUNDS

+ to ++

what is the wound size of ARTERIAL WOUNDS

small

what are the 2 wound shapes associated with ARTERIAL WOUNDS

1. circular

2. punched out look

what is the wound edge of ARTERIAL WOUNDS

cliff/stair step

what is the wound depth of ARTERIAL WOUNDS

shallow to deep

what is the wound bed + appearance of ARTERIAL WOUNDS

pale, dry, eschar

(2 degrees of decreased circulation)

what is the edema of ARTERIAL WOUNDS

minimal (localized)

is the staining ABSENT/PRESENT with ARTERIAL WOUNDS

staining absent

what is the exudate/drainage of ARTERIAL WOUNDS

minimal

venous wounds

- Location: LEs, below knee + medial malleolus

- Ankle Brachial Index (ABI): ≥ 0.8 (typical)

- Pulse: normal

- Pain: +/-

- Wound Size: large

- Wound Shape: irregular

- Wound Edge: gradually deeper toward wound center

- Wound Depth: shallow

- Wound Bed + Appearance: wet, slough (slow granulation)

- Edema: moderate to large

- Staining: moderate to large hemosiderin (purple)

- Exudate/Drainage: moderate to heavy

what are 3 locations where VENOUS WOUNDS are often located

1. LEs

2. below knee

3. medial malleolus

what is the Ankle Brachial Index (ABI) of VENOUS WOUNDS

≥0.8 (typical)

what is the pulse of VENOUS WOUNDS

normal

what is the pain of VENOUS WOUNDS

+/-

what is the wound size of VENOUS WOUNDS

large

what is the wound shape of VENOUS WOUNDS

irregular

what is the wound edge of VENOUS WOUNDS

gradually deeper toward wound center

what is the wound depth of VENOUS WOUNDS

shallow

what is the wound bed + appearance of VENOUS WOUNDS

wet, slough

(slow granulation)

what is the edema of VENOUS WOUNDS

moderate to large

what is the staining of VENOUS WOUNDS

moderate to large; hemosiderin (purple)

what is the exudate/drainage of VENOUS WOUNDS

moderate to heavy

neuropathic ulcers

- Location: foot (top, side, bottom or below MT head); 1st + 5th MT heads; phalanges

- Ankle Brachial Index (ABI): unreliable

- Pulse: varies (no pedal pulse)

- Pain: decreased/absent

- Wound Size: variable

- Wound Shape: circular, oval

- Wound Edge: round/oval w/ callous

- Wound Depth: often deep (due to discovered late)

- Wound Bed + Appearance: eschar to granulation tissue

- Edema: localized

- Staining: absent

- Exudate/Drainage: low to moderate

what is the most common location of NEUROPATHIC ULCERS

foot

what are the 3 different locations where NEUROPATHIC ULCERS are often located

1. top, side, bottom or below MT heads

2. 1st + 5th MT heads

3. phalanges

what is the Ankle Brachial Index (ABI) of NEUROPATHIC ULCERS

unreliable

what is the pulse of NEUROPATHIC ULCERS

varies (no pedal pulse)

what is the pain of NEUROPATHIC ULCERS

decreased/absent

what is the wound size of NEUROPATHIC ULCERS

variable

what are the 2 wound shapes of NEUROPATHIC ULCERS

1. circular

2. oval

what is the wound edge of NEUROPATHIC ULCERS

round/oval with CALLOUS

what is the wound depth of NEUROPATHIC ULCERS

deep

what is the wound bed + appearance of NEUROPATHIC ULCERS

eschar to granulation tissue

what is the edema of NEUROPATHIC ULCERS

localized

is the staining ABSENT/PRESENT with NEUROPATHIC ULCERS

staining absent

what is the exudate/drainage of NEUROPATHIC ULCERS

low to moderate