Depth of wounds and types of wounds

Superficial

does not break the skin (epidermis only)

very painful

red burns that blanch with pressure

Superficial partial thickness

involves the epidermis and the superficial dermis

blistering wounds that blanch with pressure

typically moist and weeping

Deep partial thickness

involved the epidermis and the deep dermis

waxy appearance, does not blanch with pressure

dry and pale

typically painless

Full thickness

involves the epidermis, dermis, and hypodermis

colorless (waxy white, or leathery gray)

typically painless

full thickness with muscle and bone involvement

involves the epidermis, dermis, hypodermis, and bone/muscle

Arterial/ ischemic ulcers

causes: poor O2/CO2 diffusion, inadequate blood flow

signs and symptoms: intermittent claudication, dependent rubor, white skin, tissue death, mild to moderate edema, weak pulse (1+)

clinical presentation: round, regular border, punched out, pink wound bed, dry necrotic tissue, usually distal, minimal drainage, pain in elevated position

treatment: dressing to provide moisture and prevent infection, restore BF

venous ulcers

causes: arteries become more elastic> blood pooling in LEs

Clinical presentations: edema, strong pulse (3+), hemosiderin deposition, spider veins, dull acheiness when on feets, irregular borders

treatment: compression, elevation, exercise in elevated position, dressing to absorb fluid

Diabetic/ neuropathic ulcers

causes: hyperglycemia, decreased sensation, increased plantar foot pressure

clinical presentation: usually along pressure points, punched out appearance, deep w/ calloused edges, not painful, minimal drainage, dry cracked skin, callous

treatment: offload, glucose control, non-occlusive dressing

Use Wegener scale to grade

Pressure ulcers

pressure to bony prominence

different stages

Treatment: offload, dressing to absorb drainage, nutrition consult and supplementation (albumin and prealbumin)

Stage 1 pressure ulcer

change in skin color/ temp

persistent red discoloration

skin is intact

non blanchable erythema

Stage 2 pressure ulcer

partial thickness

skin loss of dermis and epidermis

red, pink, moist blistered

Stage 3 pressure ulcer

full thickness

skin loss fo dermis and/or epidermis

adipose visible

slough/ eschar may be present

no tendon, muscle, or bone

Stage 4 pressure ulcer

full thickness skin less to muscle, bone, and/or supporting structures

tendon, bone, muscle exposed

Deep tissue injury pressure ulcer

deep red/purple discoloration that is not blanchable, includes blood filled blisters

Unstageable pressure ulcer

necrosis present such that base cannot be visualized

cannot be staged

Surgical wounds

treatment: wound vac

dressing to prevent

compression

nutrition

acute surgical wound/ primary intention

surgically closed

Secondary intention wound healing

not surgically closed

Inflammatory reaction is more intense, much larger amounts of granulation tissue are formed

Tertiary wound healing

delayed primary closure

days. This occurs when the process of secondary intention is intentionally interrupted and the wound is mechanically closed. This happens after granulation tissue has formed, sutures are used and opens back up.