Wound Care

34 Nurse to Nurse
• Diabetic foot ulcer: caused by trauma, pressure, peripheral
neuropathy, peripheral arterial disease, and/or infection;
located most often on the plantar surface of the foot.
• Incontinence wound: skin damage related to urinary, fecal, or
a combination of incontinence. May be partial or full thickness.
May be documented as “denuded/ing.” NOTE: do not
confuse with pressure ulcers.
• Neuropathic ulcer: partial to full thickness loss caused by
peripheral neuropathy; not exclusive in diabetics.
• Pressure ulcers: staged as I, II, III, or IV that denotes the
depth of tissue layer involvement. NOTE: do not confuse
with denuding from incontinence ulcers.
• Skin graft donor sites: surgical site where epidermis and a
specific portion of the dermis have been transferred to a wellvascularized
area of wounding on the body. It is partial thickness
and heals by reepithelialization.
• Surgical incisions: wound created by some type of operative
procedure that is closed with sutures, staples, or other techniques.
— Clean—minimal endogenous bacterial contamination
present such as with breast biopsy
— Clean-contaminated—possible endogenous bacterial contamination
present such as with appendectomy
— Contaminated—contamination present such as with trauma
— Dirty—infected tissue present such as with an abscess. 5
• Vasculitic ulcer: frequently accompanies connective tissue
diseases such as rheumatoid arthritis, lupus erythematosus,
Sjogren’s syndrome, or systemic inflammatory diseases. It is a
recurrent condition that may lead to cutaneous infarcts and
gangrene.
• Venous stasis ulcer: may be partial or full thickness loss (usually
partial) as a result of chronic venous insufficiency and/or
venous hypertension. More appropriately called venous
hypertension ulcer/wound.