NUR 300 Lecture Notes - Lecture 11: Venous Ulcer, Pressure Ulcer, Livedoid Vasculitis
Document Summary
Partial thickness: damage to epidermis and or dermis only (cut) Full thickness: damage to subcutaneous layer or deeper (puncture) Causes: trauma, incisions, vascular compromise, pressure, intentional, non-intentional. Colonized: presence of microorganisms without disease/infection. Penetrating: stab wounds, skin cuts, surgical wounds, gunshot wounds. Miscellaneous (thermal wounds, chemical wounds, bites, stings, electrical wounds. Venous: most commonly occurs above the medial or lateral malleoli. Arterial: most commonly occurs (toes, foot, ankle) Decreased blood flow from the heart to the extremities and brain. Signs and symptoms: atrophy of sc tissue, shiny and taut epidermis, thickened toenails, hair loss, dry skin. Failure of venous pressure to decrease during ambulation. Location: gaiter area above medial malleolus or anywhere on leg. Size: can be small to circumferential shallow, with irregular wound margins. Wound bed: ruddy color, granulation or fibrinous tissue. Autonomic (loss of sweating, dilated arteries: edema, healing impairment. Location: plantar or lateral aspect of foot, metatarsal heads. Size: variable, small to large with well-defined wound margins.
