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(3) PT in Special Conditions > S1L1: Wound Assessment > Flashcards

S1L1: Wound Assessment Flashcards

1
Q

Partial thickness vs. Full thickness

Destruction of both the
epidermis and dermis

A

Partial Thickness

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2
Q

Partial thickness vs. Full thickness

Pink, painful, NO yellow tissue

A

Partial Thickness

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3
Q

Partial thickness vs. Full thickness

Destruction of the dermis, epidermis, and
subcutaneous tissue

A

Full Thickness

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4
Q

Partial thickness vs. Full thickness

May expose the muscles and bones

A

Full thickness

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5
Q

Acute vs. Chronic Wounds

An injury to the skin that occurs suddenly
rather than over time

A

Acute

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6
Q

Acute vs. Chronic Wounds

It heals at the predictable and expected rate
of the normal wound healing process

A

Acute Wound

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7
Q

Acute vs. Chronic Wounds

Can occur anywhere on the body and vary from superficial scratches to deep wounds
damaging blood vessels, nerves and muscles

A

Acute Wound

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8
Q

Acute vs. Chronic Wounds

Less than 12 weeks

A

Acute Wound

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9
Q

Acute vs. Chronic Wounds

A wound that does not heal in an orderly set
of stages and in a predictable amount of time

A

Chronic Wound

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10
Q

Acute vs. Chronic Wounds

Slow to heal are often = ___ (>12 weeks)

A

Chronic Wound

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11
Q

Acute vs. Chronic Wounds

Stuck in one or more of the phases of wound
healing

A

Chronic Wound

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12
Q

Acute vs. Chronic Wounds

often remain in the inflammatory stage for too long

A

Chronic Wound

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13
Q

Acute vs. Chronic Wounds

Venous and arterial ulcers, diabetic ulcers,
and pressure ulcers are only a few examples

A

Chronic Wound

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14
Q

Acute vs. Chronic Wounds

Cause patients severe emotional and physical
stress and pain

A

Chronic Wound

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15
Q

Wound size in documented in ___
(Length x width x depth)

A

centimeters

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16
Q

Bottom of the wound (deepest)

A

Wound base

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17
Q

Vertical distance from the visible surface to
the deepest area

A

Wound depth

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18
Q

Inside the perimeter of the wound

A

Wound Edges/Margins

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19
Q

○ Skin is exposed to moisture for a prolonged
period of time
■ moisture degrades the surrounding tissue
and wound which prolongs healing

A

Macerated

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20
Q

○ Rolled edge
○ Wound edge curled under, preventing wound closure

A

Epibole

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21
Q

How to document epibole?

A

(+) Epibole on __

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22
Q

○ Fibrotic, hyper-keratotic
■ an excess in production of skin
○ Constantly exposed to repeated injuries

A

Callused

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23
Q

○ Skin surrounding the wound
○ Color should be noted

A

Periwound Area

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24
Q

Periwound Area

Minimum of __ cm

A

4 cm

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25
Q

Periwound Area Color:

Infection, trauma, inflammation

A

Red

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26
Q

Periwound Area Color:

Moisture (maceration)

A

White

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27
Q

Periwound Area Color:

Poor blood flow, trauma

A

Blue/Purple

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28
Q

Temperature:
Possible infection in the area

A

Warm

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29
Q

Temperature:
Poor blood flow in the area

A

Cold

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30
Q

How to document Periwound Temperature?

A

(+) hyperthermia/hypothermia periwound area of _____________

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31
Q

Periwound texture can be
(1) Moist
(2) Macerated/Boggy (Soft/Mushy)

How do you document it?

A

(+) maceration on periwound area on ___
(+) boggy periwound area on ________

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32
Q

o Abnormal hardening of tissue
o Caused by consolidation of edema
o May be a sign of underlying infection

A

Wound Induration

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33
Q

Maceration is _____ while Induration is _____

A

Maceration - soft and boggy to touch
Induration - firm/hard (really swollen)

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34
Q

Loss of epidermis, caused by exposure to urine,
feces, body fluids, wound exudate or friction

A

Denuded

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35
Q

T/F: Maceration and denuded can be interchangeable but usually maceration occurs initially then progresses to
denudation

A

True

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36
Q

Loss of epidermis

A

Erosion

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37
Q

T/F: Erosion may be used
interchangeably with denudation in
practice, but denudation is strictly
defined as the loss of d/t exposure
to urine, feces, or mechanical reasons like friction

A

True

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38
Q

○ Linear erosion
■ Loss of epidermis
○ Destruction of skin by mechanical means
○ Scratch

A

Excoriated

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39
Q

Can be caused by allergic reaction or prolonged exposure

A

Rashes

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40
Q

Channel or pathway that extends in any direction from the wound through the subcutaneous tissue

A

Tunneling

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41
Q

Tissue destruction underlying intact skin along the wound margins

A

Undermining

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42
Q

T/F: Tunneling is caused by shearing or friction on the area

A

False: Undermining

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43
Q

Non-viable Tissue (dead)
 Has NO blood flow

A

Necrotic Tissue

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44
Q

T/F: Necrotic tissue is Better off removed because it impedes wound healing ALWAYS

A

False: not all the time because eschar is sometimes left to help the wound heals

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45
Q

Types of Non-viable Tissue:

o yellow, green, grey
o lighter, thin, wet
o stringy

A

Slough

46
Q

Types of Non-viable Tissue:

o black, brown, grey
o darker, thicker
o harder

A

Eschar

47
Q

T/F: Eschar, slough and granulation could co-exist at
the same time

A

True

48
Q

Regeneration of the epidermis across a wound surface.

A

Epithelialization

49
Q

T/F: The epithelial wound edge is continuous and often difficult to see.

A

True

50
Q

Epithelial tissue is the outermost layer of the skin. What is its color?

A

Deep pink to pearly pink

51
Q

T/F: Epithelialization is a bad sign

A

False: Closure of the wound, healing

52
Q

● New tissue that replaces dead tissue
● Beefy, red color
● Puffy & mounded

A

Granulation Tissue

53
Q

Granulation Tissue grows from __ of the wound

A

Base

54
Q

○ Forms above the surface of the wound
○ Delays epithelialization

A

Hypergranulation Tissue

55
Q

○ Pink to dark red
○ Highly vascularized
○ Striated, grooved, or ridged

A

Muscle tissue

56
Q

Tendon Attaches muscle to bone. It is ____ when healthy

A

Shiny

57
Q

● Hypodermal area
● Covering over the muscles
● Shiny & white
● Great organizer

A

Fascia

58
Q

● Shiny & smooth, White in color

A

Bone

59
Q

WOUND BASE COLOR

Healthy tissue,
Good blood flow

A

Beefy Red

60
Q

WOUND BASE COLOR

Poor blood flow,
Anemia

A

Pale Pink

61
Q

WOUND BASE COLOR

Engorged, swelling, high bacteria levels (infection), trauma (exposed to repetitive trauma)

A

Purple

62
Q

WOUND BASE COLOR

Non-viable, necrotic tissue

A

Black/Brown

63
Q

WOUND BASE COLOR

Non-viable tissue, slough

A

Yellow

64
Q

WOUND BASE COLOR

Non-viable tissue, active infection
○ Similar to the color of phlegm

A

Green

65
Q

WOUND BASE COLOR

○ Macerated, poor blood flow

A

White

66
Q

T/F: WOUND BASE COLOR Would dictate if wound is healing properly

A

True

67
Q

How to document EXUDATE (DRAINAGE)?

A

Documented by type & amount (approximate)
○ (+) yellow exudate on wound, ~1 tsp on ___

68
Q

TYPES OF EXUDATES

Thin clear watery plasma

A

Serous

69
Q

TYPES OF EXUDATE

Red or bloody

A

Sanguinous

70
Q

TYPES OF EXUDATE

Thin, watery, pale red to pink, plasma with RBC

A

Serosanguinous

71
Q

TYPES OF EXUDATE

Thick, opaque tan, brown color

A

Purulent

72
Q

TYPES OF EXUDATE

COLOR: Clear straw colored

A

Serous

73
Q

TYPES OF EXUDATE

COLOR: Cloudy

A

Fibrinous

74
Q

TYPES OF EXUDATE

COLOR: Red

A

Sanguinous

75
Q

TYPES OF EXUDATE

COLOR:Murky yellow/ Cream/ Coffee

A

Seropurulent

76
Q

TYPES OF EXUDATE

COLOR: Yellow/grey/brighter green

A

Purulent

77
Q

TYPES OF EXUDATE

COLOR: Dark, Blood-stained

A

Haemopurulent

78
Q

TYPES OF EXUDATE

COLOR: Dark red

A

Hemorrhagic

79
Q

TYPES OF EXUDATE

COLOR: Opaque/ Pink

A

Serosanguinous

80
Q

TYPES OF EXUDATE

CONSISTENCY: Viscous / stick

A

Haemopurulent

81
Q

TYPES OF EXUDATE

CONSISTENCY: Thicker / sticky / creamy

A

Seropurulent

82
Q

TYPES OF EXUDATE

CONSISTENCY: Thin watery

A

Serous
Fibrinous
Serosanguinous
Sanguinous

83
Q

TYPES OF EXUDATE

CONSISTENCY: Thick / sticky

A

Hemorrhagic
Purulent

84
Q

TYPES OF EXUDATE

SIGNIFICANCE: Normal

A

Serous

85
Q

TYPES OF EXUDATE

SIGNIFICANCE: May indicate fibrin strands present. This is normal

A

Fibrinous

86
Q

TYPES OF EXUDATE

SIGNIFICANCE: May indicate the presence of red blood cells and capillary damage from, e.g. traumatic dressing removal or surgery

A

Serosanguinous

87
Q

TYPES OF EXUDATE

SIGNIFICANCE:
- May indicate trauma to blood vessels.
- May indicate low protein content d/t malnutrition.
- Venous or congestive cardiac failure.
- May indicate presence of fistula

A

Sanguinous

88
Q

TYPES OF EXUDATE

SIGNIFICANCE: May indicate a bacterial infection and/ presence of necrotic liquid / tissue

A

Seropurulent

89
Q

TYPES OF EXUDATE

SIGNIFICANCE: May indicate infection.

Contains pyogenic (pus generating) organisms and other inflammatory cells Consequent damage to dermal capillaries leads to blood leakage

A

Purulent

90
Q

TYPES OF EXUDATE

SIGNIFICANCE: Will indicate an infection and will contain neutrophils, dead/dying bacteria and inflammatory cells.

Consequent damage to dermal capillaries leads to blood leakage.

A

Haemopurulent

91
Q

TYPES OF EXUDATE

SIGNIFICANCE: Indicates infection and/or trauma.

Capillaries are so friable they readily break down and spontaneous bleeding occurs.

Not to be confused with bloody exudate produced by over-enthusiastic debridement.

A

Hemorrhagic

92
Q

AMOUNT OF EXUDATE

 Wound tissues are very moist
 Drainage < 25% of bandage is covered by the exudate

A

SMALL / MINIMAL

93
Q

AMOUNT OF EXUDATE

 Wound tissues wet
 Drainage occupies 25-75% of
bandage

A

Moderate

94
Q

AMOUNT OF EXUDATE

 Tissues filled with fluid
 Drainage: > 75% of bandage

A

Large / Copious

95
Q

EDEMA GRADING

Indentation is barely detectable

A

1+

96
Q

EDEMA GRADING

Slight indentation is visible when skin is depressed,
returns to normal in 15 seconds

A

2+

97
Q

EDEMA GRADING

Deeper indentation occurs when pressed and
returns to normal within 30 seconds

A

3+

98
Q

EDEMA GRADING

Indentation lasts for more than 30 seconds

A

4+

99
Q

PULSE QUALITY

no pulse

A

0

100
Q

PULSE QUALITY

weak pulse, difficult to palpate

A

1+

101
Q

PULSE QUALITY

Palpable but not normal, diminished

A

2+

102
Q

PULSE QUALITY

Normal, easy to palpate

A

3+

103
Q

PULSE QUALITY

Bounding, very strong, may imply the possibility of an aneurysm or other pathological conditions

A

4+

104
Q

○ Recognize and evaluate each patient’s risk factors
○ Identify which risk factors can be removed or modified daily
○ Ex. Norton Plus Pressure Ulcer Scale, Braden Scale
for Predicting Pressure Sore Risk,

A

RISK Assessment Tools

105
Q

Assessment and documentation should be done at least ____!

A

Weekly

Note: More frequent if with complications and changes in wound characteristics

106
Q

T/F: Documenting wound assessment includes:
○ Size
○ Location
○ Tissue types
○ Exudate
○ Odor
○ Surrounding tissue (periwound area)
○ Pain

A

True

107
Q

help maintain turning schedules to reduce pressure injuries. Pillows can also be used.

A

Body positioning wedges

108
Q

cushion foot and suspend heel to relieve pressure while reducing skin trauma. This can also be worn by pts with existing wounds.

A

Heel protectors

109
Q

help protect fragile skin from skin tears, bruising, and friction. If the skin already has an issue, it can protect from further injury.

A

Skin sleeves

110
Q

keep extremities positioned properly to reduce joint contracture and skin issues.

Ex. for bed bound pts who have resting hand splint, they keep extremities positioned properly to reduce joint contractures and skin issues. Quadriplegic pts need splint to maintain their hands in a functional position.

A

Contracture Braces

(3) PT in Special Conditions (40 decks)

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