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ndnqi: other Wound Types and skin injuries

Terms in this set (47)

1. A wound on the foot of a person with diabetes.

2. causes:
>Peripheral neuropathy
-Sensory neuropathy leads to loss of protective sensation
-Motor neuropathy causes an imbalance between flexor and extensor muscles leading to foot deformities that create abnormal bony prominences and pressure points
-Autonomic neuropathy alters blood flow in the foot and sweat and oil gland function leaving skin dry
>Peripheral vascular disease with poor microvascular circulation
Leads to tissue ischemia
>Repetitive mechanical stress or excessive pressure
Less well noticed or not noticed because of sensory neuropathy
>Poorly controlled blood glucose levels
Accelerates the development of arterial disease

4. Additional Risk Factors:
Visual impairment or retinopathy
Poor foot care preventive practices
Previous foot ulcerations

5. Location
-Common sites - toe interphalangeal joint, metatarsal head, plantar surface of the foot, under heel

6. Associated Skin Assesssment:
Decreased sensation in the foot
Warm skin, may be dry
Plantar fat pad atrophy
Foot deformities such as hammer toe, claw toe, and Charcot's foot

7. Wound Characteristics:
Depth varies from partial thickness to full thickness with bone involvement
Regular wound margins
Often surrounded by a rim of calloused tissue
Low to moderate amount of drainage

8.Classification Systems:
1. Meggit-Wagner Classification System
Grade 1 - Superficial diabetic ulcer
Grade 2 - Ulcer extends to ligament, tendon, or joint without abscess or osteomyelitis
Grade 3 - Deep ulcer with abscess or osteomyelitis
Grade 4 - Gangrene to portion of forefoot
Grade 5 - Extensive gangrene of foot

2. University of Texas Diabetic Wound Classification System
Stage A to D based on infection and ischemia
Grade 0 to 3 based on ulcer depth
A form of moisture-associated skin damage.

Caused by prolonged exposure to urine, stool, or both that irritates the skin leading to erosion.
Urine overhydrates exposed skin increasing the risk for friction injury
Ammonia in urine elevates skin pH impairing its barrier function
Fecal enzymes weaken epidermal integrity. Liquid stool is particularly irritating to the skin.

Other names for Incontinence-Associated Dermatitis have included Perineal Dermatitis and Diaper Dermatitis.

2. Risk factors:
Use of absorptive products that cover the skin (diapers, incontinence brief, incontinence pad)
Diminished tissue tolerance
Influenced by patient age, health status, nutritional status, oxygenation, body temperature
Impaired toileting ability

3. locations:
Buttocks, perineum, perianal area - may extend to inner and posterior thighs

4. Associated Skin Assessment:
Diffuse erythema of the skin surface
Erythema is brighter red in persons with lighter skin tones
Erythema is subtle red in persons with darker skin tones
Edema may be present
Areas of skin maceration may be observed
Secondary cutaneous infection
Irritated/impaired skin is more easily invaded by microorganisms
A secondary fungal infection (from Candida Albicans) is seen as a maculopapular rash with satellite lesions

5. Wound Characteristics:
Usually partial thickness skin loss
Ranges from one or more islands of erosion to extensive denudation of the epidermis and dermis
Irregular and indistinct borders/edges
No exudate or clear, serous exudate which can cause the skin to glisten
No slough or eschar
Burning pain, itching

6. Classification System:
1. Incontinence-Associated Dermatitis Intervention Tool
2. Incontinence-Associated Dermatitis Severity (IADS) Instrument
-Body location of incontinence-associated dermatitis
-Magnitude of erythema
-Presence or absence of skin erosion
-Presence or absence of skin rash