Wound Care and Inflammation

Normal Skin

Layers of the skin Epidermis - avascular Dermis Subcutaneous tissue (hypodermis)

Ulcer

cavity in tissue

Antibacterials (contraindicated for non-infected wounds)

Bacitracin/baciguent Neosporin/neomysin sulfate Silvadene/silver sulfadiazine Furacin/nitrofurazone Sulfamylon/mafenide acetate Bactroban/mupirocin Gentamicin/Geramycin

Hyperbaric O2 (HBO)

100% O2 delivered in a sealed room Increase O2 for cell metabolism Enhanced growth factors Topical better than enclosed room

Stages of Pressure Ulcers (decubitus ulcers)

Stage I: Skin is intact and red Stage II: Loss of skin integrity in epidermis and dermis Stage III: Loss of skin integrity into subcutaneous tissue Stage IV: Involvement of all layers of skin plus muscle, bone and tendon

Non-forceful Irrigation

ASAP non-forceful irrigation with minimal pressure or force Pouring solution over wound Use a bulb syringe Several products packaged for saline wound cleaning Pour or spray at gentle pressure Infected wounds cleaned with non-forceful irrigation Wounds with necrotic tissue or debris respond to a more forceful cleansing Clean wounds/new tissue growth use irrigation only to remove excess endogenous fluids or residue from dressing products

Scar management

After wound fills with collagen tissue the tissue must be remodeled Contraction of scar tissue leads to disfigurement and a loss of function especially if over a joint Disfigurement and dysfunction worst after a thermal injury Usually manage scar tissue with pressure garments, stretching, orthotics, positioning, massage, use of topical adjuncts such as silicone gel sheets and putty (Fig 17-53, 17-54 p 686) Scarring continues for 6 to 24 months

Topical Agents

Antiseptics, disinfectants, antimicrobials, antibiotics and analgesics used less than previously Found to be cytotoxic to white blood cells Cause adverse reactions or ineffective Endogenous fluid preferred

Artrial Ulcer

Arterial insufficiency ulcers (also known as Ischemic ulcers or Ischemic wounds) are mostly located on the lateral surface of the ankle or the distal digits. They are commonly caused by peripheral artery disease (PAD) The ulcer has punched-out appearance. It is intensely painful. It has gray or yellow fibrotic base and undermining skin margins. Pulses are not palpable. Associated skin changes may be observed, such as thin shiny skin and absence of hair. They are most common on distal ends of limbs. The management of arterial insufficiency ulcers depends on the severity of the underlying arterial insufficiency. The affected region can sometimes be revascularized via vascular bypass or angioplasty. If infection is present, appropriate antibiotics are prescribed. When proper blood flow is established, debridement is performed. If the wound is plantar (on walking surface of foot), patient is advised to give rest to foot to avoid enlargement of the ulcer. Proper glycemic control in diabetics is important. Smoking should be avoided to aid wound healing. Antibiotics, if an infection is present Anti-platelet or anti-clotting medications to prevent a blood clot Topical wound care therapies Compression garments Prosthetics or orthotics, available to restore or enhance normal lifestyle function These ulcers are difficult to heal by basic wound care and require advanced therapy, such as hyperbaric oxygen therapy or bioengineered skin substitutes. Arterial Ulcer Treatment Arterial ulcer treatments vary, depending on the severity of the arterial disease. Depending on the patient's condition, the physician may recommend invasive testing, endovascular therapy or bypass surgery to restore circulation to the affected leg. The goals for arterial ulcer treatment include: Providing adequate protection of the surface of the skin Preventing new ulcers Removing contact irritation to the existing ulcer Monitoring signs and symptoms of infection that may involve the soft tissues or bone On the feet - often on the heels, tips of toes, between the toes where the toes rub against one another or anywhere the bones may protrude and rub against bed sheets, socks or shoes. They also occur commonly in the nail bed if the toenail cuts into the skin or if the patient has had recent aggressive toe nail trimming or an ingrown toenail removed. Causes: Poor circulation, often caused by arteriosclerosis Other disorders of clotting and circulation that may or may not be related to atherosclerosis Diabetes Renal (kidney) failure Hypertension (treated or untreated) Lymphedema (a buildup of fluid that causes swelling in the legs or feet) Inflammatory diseases including vasculitis, lupus, scleroderma or other rheumatological conditions Other medical conditions such as high cholesterol, heart disease, high blood pressure, sickle cell anemia, bowel disorders History of smoking (either current or past) Pressure caused by lying in one position for too long Genetics (ulcers may be hereditary) A malignancy (tumor or cancerous mass) Infections Certain medications

Arterial Insuffeciency Wound

Arterial insufficiency ulcers. Note the wounds on the distal toes with adherent yellow slough-covered bases. Wound beds appears to be slightly dry, rather than wet or moist. Previous amputation of the second digit and metatarsal due to a prior non-healing neuropathic ulcer.

Pruritus

Associated with Allergic responses Chemical irritation due to insect bites Infestations by parasites, e.g., scabies Mechanism not totally understood Histamine release is known. Infection may result from breaking the skin barrier. Due to scratching

Arterial Leg Ulcer Characteristics

At tips of toes or between toes and over phalangeal heads above laterial malleolus, over the metatarsal head, on the side or sole of the feet Minimal/ no hair Thin, dry and shiny skin Thickened toe nails Leg may be cool Leg becomes pale when elevated May have neuropathy Nil or diminished leg and foot pulses

Creams and lotions

Bacitracin Neosporin Once they lose strength can trap bacteria and encourage bacterial growth Wound needs to be cleaned regularly to remove contamination Too frequent cleansing may disrupt healing process Theses preps provide moisture to a dry wound but may create a greasy wound bed May delay epithelial cell migration Better moisture can be from Aquaphor

Anticeptics

Betadine Only for wounds infected with staphlococcus aureus Contraindicated for non-infected wounds Dakin's, Bleach and Boric Acid, Sodium Hypochlorite (Bleach) Cytotoxic even in very diluted form Damages fibroblasts, endothelial cells and granulation tissue Contraindicated for non-infectious wounds Acetic acid More damaging to fibroblasts than to bacteria Only used for wounds infected with pseudomonas aeruginosa Oxidizing agents: Hydrogen Peroxide solution Temporary antimicrobial activity Bubbling used for non-selective debridement Cytotoxic unless very diluted

PT Interventions

Cleansing WP Cleansing/non-selective mechanical debridement Problems: cross-contamination, dependant position, loss of endogenous fluids, core temperature changes, mechanical disruption of granulation tissue, epithelial cells and new skin grafts; saturates skin and wound tissue with possible maceration and skin breakdown, inactivate normal skin defenses If necessary to use for wounds that need intensive cleaning: low agitation only, small part of body for short period (5-10 minutes; neutral warmth

Lymphedema

Chronic disorder Accumulation of lymph fluid Mechanical insufficiency of lymph system Unable to manage lymph fluid present in body Primary lymphedema Congenital/heredity: fewer lymphatic vessels Secondary lymphedema Injury to lymphatic system Surgery or radiation as part of breast cancer treatment CVI Pressure ulcers occur frequently when person immobilized for prolonged periods Risk factors: Hospitalized elderly, incontinent, underweight, SCI During surgery, confusion, DNR Increased risk of death for elderly Stage I: Skin is intact and red Stage II: Loss of skin integrity in epidermis and dermis Stage III: Loss of skin integrity into subcutaneous tissue Stage IV: Involvement of all layers of skin plus muscle, bone and tendon 1+ Barely detectable impression when finger is presssed into skin. 2+ Slight indentation. 15 seconds to rebound 3+ Deeper indentation. 30 seconds to rebound. 4+ > 30 seconds to rebound.

Appendages of the Skin

Hair follicles Stratum basale - hair producing Arrector pili muscle associated to hair follicle Sebaceous glands Produce sebum Secretion increases at puberty - influence of sex hormones Sweat glands Eccrine - all over body Apocrine Axillae, scalp, face, external genitalia

Carbuncles

Collection of furuncles that coalesce to form a large infected mass

Diagnostic Tests for Skin Lesions

Culture and staining of specimens Bacterial infections Biopsy Detection of malignant changes Safeguard prior to or following removal of skin lesions Blood tests Helpful in diagnosis of conditions due to allergy or abnormal immune reaction Skin testing using patch or scratch method

Deep Vein Thrombosis

Deep vein thrombosis, or DVT, is caused by a blood clot in a deep vein and can be life-threatening. Symptoms may include swelling, pain, and tenderness, often in the legs. Risk factors include immobility, hormone therapy, and pregnancy.

Pressure Relieving Devices

Educate patient concerning pressure relief

Classification by Level of Injury or Necrosis with any wound:

Epidermis = Superficial wound (sunburn/blister) Dermis = Partial thickness wound Subcutaneous tissue = full thickness wound

Functions of the Skin

First line of defense Prevents excessive fluid loss Control of body temperature Sensory perception Synthesis of vitamin D

Clinical Presentation of Wound

First signs Blanching erythema Increased skin temp Superficial abrasion, blister or shallow open wound Indicates dermis affected Full thickness visible as a crater Minimal bleeding Tissues indurated/warm Eschar formation Tunneling/undermining often present Risky areas: sacrum, coccyx, greater trochanter, ischial tuberosity, calcaneus, lateral malleolus

Interventions

Foot care program Wound care Decreasing weight-bearing stresses Crutches, walkers, walking cast/splint Special footwear Exercise, orthotics and modalities

Wounds

Gait, locomotion and balance Integument integrity Observe and palpate skin Fibrosis skin thick and difficult to lift off dorsum of foot or hand Coloration Abnormal colors: purple, red, brown Possible Raynaud's or DVT Temperature Poor arterial circulation if temp decreased Increased may be infection

Ganegrene

Gangrene is a potentially life-threatening condition caused by a critically insufficient blood supply (necrosis). This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood supply to the affected tissues, which results in cell death. Causes-Diabetes, Atherosclerosis, Peripheral Artery Disease, Smoking, Trauma or Serious injury, Obesity and Raynauds Disease and frostbite. Treatements-maggot therapy, debriedment, antibiotics, oxygen therapy, angioplasty Gangrene most commonly affects the feet, toes, hands, and fingers. Gangrene can also occur inside the body in abdominal organs such as the intestines.

Proliferation Phase

Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size.

Verrucae (Warts)

HPVs types 1 to 4 Frequently develop in children and young adults Plantar warts are common. Spreads by viral shedding of the skin surface May resolve spontaneously within time Genital warts (HPV types 6 and 11)

Wound Care

History Tests and Measurement Aerobic capacity/endurance Height and weight Volumetric measurements Girth measurements Palpation/pitting scale p. 659 Arousal, attention, cognition Assistive/adaptive equipment Circulation Temperature of skin

Dressings

Hundreds of choices (see Appendix G&H) Gauze/fiber (not a good choice) Leaves contaminated fibers in the wound, dessication, permeable to bacteria Adherent to wound Releases bacteria into air Causes pain if adheres to wound Gauze ribbons used to maintain a drainage opening for tunneling wound Can be used as secondary dressing Do not pack tightly Good if exudate heavy

Hypergranulation

Hypergranulation tissue is believed to occur as a result of an extended inflammatory response. We believe it may be caused by a reaction to the tube - the body is in fact "walling off" the tube. Pressure, moisture and friction may also contribute to the development of hypergranulation tissue. Hypergranulation tissue is the body's way to fight the gastrostomy tube - the body does not think the tube belongs there. Hypergranulation tissue is not harmful. Hypergranulation tissue is red, moist and bleeds when rubbed. Hypergranulation tissue oozes a yellow, sticky drainage. Hypergranulation tissue can affect how the gastrostomy or jejunostomy tube fits in the stoma. Hypergranulation tissue is common in the first 3 months.

Venous Ulcers

Inadequate drainage of venous blood Usually develop edema Skin ulcerations or abnormalities CVI most common cause of leg ulcers Inadequate venous circulation resulting in: 80% of all leg ulcers caused by venous disease Risk factors include: aging, lack of exercise, obesity, long hours standing/sitting, heredity Hx of DVT, pregnancy, family Hx, vigorous activity in presence of risk factors Occur secondary to inadequate functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration. Irregular shape Pain mild to moderate Pedal Pulses Normal Increased Edema Flaking dry skin

Anelgesics

Lidocaine EMLA (a mixture of local anesthetics) Amitriptyline Growth factors Endogenous growth factors in wound bed fluid If delayed or stopped growth, can be added topically Procurin or Regranex Gel Topical agents for acute wounds (trauma or burns) Providone-iodine or Silvadene in early management of acute traumatic wounds Discontinue ASAP

Venous Leg Ulcer Characteristics

Lower 1/3 of leg Pretibial Area Anterior to medial malleous Reddish brown pigmentation, known as Haemosiderin Evidence of past healed ulcers Oedema,(a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body) that may leak and cause maceration, varicose eczema, itchy skin and scale Dilated and tortuous superficial veins Legs may be warm Hair on legs Normal leg and foot pulses Why Ulcer Characteristics

The ABCD of Melanoma

Melanoma is suspected in any nevus that shows: Change in appearance Change in border Change in color Increase in diameter

Fungal Infections (Mycoses)

Most are superficial. Candida is associated with diabetes. May spread systemically in immunocompromised Tinea - several types Tinea capitis - infection of the scalp Tinea corporis - infection of the body, particularly nonhairy parts Tinea pedis - athlete's foot Tinea urguium - infections of the nails; in particular, toenails

Wound Management

Muscle performance Orthotic, protective or supportive devices Pain Posture ROM Self-care & Home Management Sensation Ventilation/respiration

Phases of wound healing

Phases of Wound Healing

General Treatment Measures

Pruritus- Topical agents to reduce sensation May be treated by antihistamines or glucocorticoids Avoidance of allergens Reduce risk of reoccurrence Infections-may require antibiotic treatment Precancerous lesions Surgery, laser therapy, electro-dessication, cryosurgery

Wound Cleaning

Pulsatile lavage with suction (PLWS) Removes irrigation fluid, wound exudate and loose debris Advantages over WP Pulsed irrigation Simultaneous suction removes irrigation fluid, wound exudate and debris Less water, less staff support, less treatment time, less clean-up Can be done at home, bedside (no family in room during procedure) Able to deliver topical antibiotics, antiseptics, and antibacterial solutions Disadvantages Risk of overuse with clean, granulating tissue Risk of trauma to newly formed tissue (from plastic tips, pulsed irrigation and/or suction) Other: used by experiences therapists only, must wear PPE, extra landfill, increased labor cost

Guidelines to Reduce Risk of Skin Cancers

Reducing sun exposure at midday and early afternoon Covering up with clothing Remaining in shade Wearing bread-brimmed hats to protect face and neck Applying sunscreen or sun block Protecting infants and children from exposure and sun damage to skin

Debriedment

Removal of foreign material and dead/damaged tissue Removal of infected/devitalized tissue important to prevent/control bacterial growth, encourage normal cellular activity in wound bed, enhance rate of tissue repair Non-selective debridement removes all tissue: necrotic and living Selective debridement removes tissue under control, slower process Avoid making wound bleed

Pulsatile lavage with suction (PLWS)

Removes irrigation fluid, wound exudate and loose debris Advantages over WP Pulsed irrigation Simultaneous suction removes irrigation fluid, wound exudate and debris Less water, less staff support, less treatment time, less clean-up Can be done at home, bedside (no family in room during procedure) Able to deliver topical antibiotics, antiseptics, and antibacterial solutions Disadvantages Risk of overuse with clean, granulating tissue Risk of trauma to newly formed tissue (from plastic tips, pulsed irrigation and/or suction) Other: used by experiences therapists only, must wear PPE, extra landfill, increased labor cost

Neuropathic Ulcer

Ring of callus around the wound at the plantar aspect of the metatarsal heads that is typical of neuropathic ulcerations. The pressure point caused by the Charcot deformity is callous and there is evidence of subdermal hemorrhaging. Previous amputations and surgical incisions are also evident. Location on body Usually located at increased pressure points on the bottom of the feet. However, neurotrophic ulcers related to trauma can occur anywhere on the foot. Appearance Base: Variable, depending on the patient's circulation. It may appear pink/red or brown/ black. Borders: Punched out, while the surrounding skin is often calloused. Who is affected Neurotrophic ulcers occur primarily in people with diabetes, although they can affect anyone who has an impaired sensation of the feet. The wound should be thoroughly debrided down to healthy, bleeding tissue. Often there is infection underneath the superficial layer of necrotic tissue, even extending down into the bone and bone marrow. Debridement allows for better assessment of the ulcer and any underlying infections, as well as providing a better healing environment. Ideally, the wound environment should be moist while healing, but also allowed to breathe. The exact properties of the dressing should be matched to those of the wound.

Rubor Test

Rubor of Dependency Test Have patient lie on his back and raise one of his legs about 45-60 degrees. Hold leg up for a minute. If his circulation is poor, his foot will turn grayish-white (pallor) when it is elevated, and then will turn bright red (rubor) when you sit him back up and let his foot dangle.

Neuropathic Ulcer

Secondary complication usually associated with combination of ischemia and neuropathy. Often associated with diabetes Frequently found on plantar surface of the foot with a well defined callus rim Good granulation with little to no drainage Patients rarely report pain (diminished sensation Pedal pulsed diminished or absent

Selective debridement

Sharp Using scalpel, scissors, forceps Gold Standard" of debridement (PT only) Contraindicated for vascular wounds with decr blood flow and eschar Chemical or Enzymatic topical agents that contain enzymes that dissolve necrotic tissue Advantages Selective Minimal patient discomfort Application procedures simple Disadvantages Dermatitis Frequent dressing changes disrupt wound bed, eschar which may have to be "cross-hatched with a scalpel so enzyme can penetrate

Orthotics

Splinting: resting splints, dynamic splints, prevent skin breakdown, protect fragile skin from breakdown Neuropathic Walker custom made boot to provide weight distribution 17-51, 17-52 p. 685-686 Cast shoes (little cushioning/little control of foot) Extra depth shoes redirects pressure from bony prominences

Homans Test

The Homans' sign test was originally described to be conducted in the following order: In the supine position, the knee of the suspected leg of the patient should be flexed. The examiner should then forcibly and abruptly dorsiflex the patient's ankle. The examiner observes whether or not the patient reports pain in this calf and popliteal region. Pain indicates a positive sign.

Phases of Wound Healing

The entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. This overview will help in identifying the various stages of wound healing. I. Inflammatory Phase A) Immediate to 2-5 days B) Hemostasis Vasoconstriction Platelet aggregation Thromboplastin makes clot C) Inflammation Vasodilation Phagocytosis II. Proliferative Phase A) 2 days to 3 weeks B) Granulation Fibroblasts lay bed of collagen Fills defect and produces new capillaries C) Contraction Wound edges pull together to reduce defect D) Epithelialization Crosses moist surface Cell travel about 3 cm from point of origin in all directions III. Remodeling Phase A) 3 weeks to 2 years B) New collagen forms which increase tensile strength to wounds C) Scar tissue is only 80 percent as strong as original tissue

Skin Lesions

The physical appearance of the lesion is necessary to make a diagnosis. Skin lesions may be caused by: Systemic disorders Liver disease Systemic infections Chickenpox Allergies to ingested food or drugs Localized factors

How to determine the type of skin lesions

Types of lesions Location Length of time the lesion has been present Changes occurring over time Physical appearance Color Elevation Texture Type of exudate Presence of pain or pruritus (itching)

Vessicle

Thin wall, raised, fluid filled, blister

Maturation Phase

This wound, located anterior, below the patella, is actively contracting toward the center while the perimeter is remodeling. Note the changes in tissue quality. Near the wound edge, less granulation tissue has been formed and the scar is less mature and more pink in color Farther out, the scar is closer to the patient's natural color and flush with the surrounding skin. Scar tissue is remodeled in the maturation phase and capillaries disappear from the granulation tissue leaving a white scar.

Trophic Changes

Trophic changes Dry, shiny skin Decreased or absent hair on LE Thick toe nails Pain Often from intermittent claudication Rest pain at night that awakens patient Special tests Rubor test Homan's test Pain in calf with foot DF Other symptoms: change in skin temp or skin color, pain in calf, swelling

Venous Ulcer

Typical venous insufficiency ulcer. The wound is located near the medial malleolus. Wound bed is approximately 85% adherent yellow slough, with approximately 15% granulation tissue at the wound margins There is scar tissue surrounding the ulcer, indicating the wound was once significantly larger than in the current photograph. There is extensive hemosiderin deposition posterior, superior, and anterior to the ulcer Venous Ulcer Treatment Venous ulcers are treated with compression of the leg to minimize edema or swelling. Compression treatments include wearing compression stockings, multi-layer compression wraps, or wrapping an ACE bandage or dressing from the toes or foot to the area below the knee. The type of compression treatment prescribed is determined by the physician, based on the characteristics of the ulcer base and amount of drainage from the ulcer. Types of dressings include: Moist to moist dressings Hydrogels/hydrocolloids Alginate dressings Collagen wound dressings Debriding agents Antimicrobial dressings Composite dressings Synthetic skin substitutes Appearance Base: Red in color and may be covered with yellow fibrous tissue. There may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant. Borders: Usually irregularly shaped. The surrounding skin is often discolored and swollen. It may even feel warm or hot. The skin may appear shiny and tight, depending on the amount of edema (swelling). Who is affected-Venous stasis ulcers are common in patients who have a history of leg swelling, varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs.

Neuropathy

Typically diabetic neuropathy Related to high levels of glucose May effect cranial nerves, peripheral nerves or autonomic nerves Related to high levels of glucose in body Typically in LE Foot insensitive And subsequent ulcerations Diabetic patients often have co-existing arterial problems Clinical presentation Usually on weight bearing surface Anesthetic, round, over boney prominence Sensory neuropathy Patient unable to sense pain/pressure Mechanical/Repetitive stress most common cause Motor neuropathy Decreased/loss of intrinsics Hammer-toe/claw toe Foot drop

Ultraviolet radiation

UVA, UVB, UVC Cutaneous and bacteriocidal effects Increased blood flow, increased granulation tissue Destruction of bacteria Stimulation of Vit D Thickening of stratum corneum UVC kills staphylococcus aureus Dressing must be removed

Mechanical modalities

Ultrasound Stimulates cell activity Accelerates wound contraction and skin repair Promotes wound contraction Strengthens scar tissue Cover wound with a sheet of hydrogel or amorphous hydrogel Deliver US with hand-held applicator to periwound area and/or the wound bed

Electric stimulation

Used for chronic and acute wounds Fig 17.21 Decr bacteria, incr blood flow, reduce wound pain Human skin and all wounds have measurable electrical currents ES supports or alters natural current to accelerate wound healing Direct method uses saline soaked gauze or hydrogel dressing indirect method uses electrodes to straddle the wound with gel electrodes

Thermal/non-thermal diathermy

Used to treat chronic open wounds Provide thermal and non-thermal effects PSWD heat superficial and deep tissue CSWD treats deep muscle and joint tissues Increase fibroblasts, collagen, tissue perfusion and metabolic rate Treatment delivered without touching skin Pad placed over wound dressing, compression garment or cast

Autolytic debridement

Using endogenous enzymes in wound bed to digest devitalized tissue and promote granulation tissue Body's natural enzymes in contact with wound for 3-7 days Increasing moisture content of slough and necrotic tissue , autolytic activity facilitated Least invasive/ most selective Inexpensive/painless and biocompatible

Thermotherapy (Radiant Heat)

Warming wounds to promote healing Most wound below body temperature Warm-up Wound Therapy System Chronic wound heals best at body temperature Heat delivered though a non-contact, semi-occlusive dressing Warming card placed in sleeve on top of wound Card warms to 100 deg F Can be left in place 72 hours or until absorbent edges become saturated Availability is limited

Non Selective debridement

Wet-to-dry dressings Wet gauze applied to wound bed and allowed to dry on wound Removal of dressing debrides the wound Removes necrotic tissue but also endogenous fluids, fibrin and other cells critical to healing process Not a good alternative Surgical debridement Rapid results for life-threatening necrosis, large wounds, tunneling wounds and necrotic/infected bone

CVI

What is chronic venous insufficiency (CVI)? Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. CVI causes blood to "pool" or collect in these veins, and this pooling is called stasis.

Pressure Ulcers

Wound caused by pressure to dermis and vascular structures typically over a boney area Superficial skin can tolerate pressure 2-8 hours before breakdown Deeper muscles, fat, CT for 2 hours or less Thus damage may be not visible initially Pressure ulcers occur frequently when person immobilized for prolonged periods Risk factors: Hospitalized elderly, incontinent, underweight, SCI During surgery, confusion, DNR Increased risk of death for elderly

Maturation Phase Wound

Wound closure

Inflammatory Phase

Wound in the inflammatory phase of wound healing. Notice the edema of the great toe as well as the erythema extending from the wound proximally to the area of the metatarsophalangeal joint. The wound bed is covered with a thin layer of yellow slough. The great toe feels slightly warm to the touch. Additionally, the patient reports the toe is tender to the touch

Proliferation Phase

Wound in the proliferative phase of wound healing. The small endothelial buds (1) which can be seen within the wound bed indicate angiogenesis. The pale pink epithelial cells at the wound edge (2) are evidence of epithelialization.

Wound Examination

Wound size and depth Superficial, partial and full thickness Pressure ulcer staging Stage 1: persistent redness in light skin, darker skin red, blue or purple hue Stage 2: partial skin loss involving epidermis/dermis; superficial and presents as abrasion; blister or shallow crater Stage 3: full thickness loss of skin;necrosis of subcu tissue; deep crater w/wo undermining Stage 4: full thickness, extensive destruction, necrosis; damage to muscle/bone, joint capsule, tendon

Arterial Ulcers

Wounds resulting from arterial insufficiency occur secondary to ischemia from inadequate circulation of oxygenated blood often due to complicating factors such as atherosclerosis Pain usually severe Pedal pulses diminished or absent Thin shiny skin Smooth edges 10-25% of leg ulcers from arterial disease Usually lateral malleoli or dorsum of feet/toes Usually caused by atherosclerotic occlusion Often have diabetes as well Abnormal nail growth, decr leg/foot hair, dry/pale skin Skin cool to palpation Pain in legs/foot (intermittent claudication)

Fissure

crack in tissue

Nodule

firm, raised, deep

Macule

flat, circuscribed

Postule

raised, filled with exudate

papule

small solid elevation

Fibrosis

the thickening and scarring of connective tissue, usually as a result of injury.