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Flashcards in 2] Wound Assessment Deck (58):
1

Why is assessment and documentation important?

For communication
Denied payment for stage 3 and 4 pressure injuries not documented on admission in some settings
Side with most data wins
If you didnt write it, you didnt do it

2

Diagnoses that are risk factors

Diabetes
Plegias
Urinary incontinence or chronic bowel
Sepsis
Terminal illness
C-diff
Immobile
Hip surgery

3

Measure wounds in ?

Cm

4

What is undermining

Open skin at the surface caused by shearing

5

Documentation of measure of a wound tunneling and undermining

Undermining from 3:00 - 7:00 with depth of 1.5 cm at 7:00

6

passageway belowsurface of skin in
any direction from
surface or edge of
wound

Tunneling

7

thick, leathery, necrotic, devitalized
tissue

Eschar

8

Slough is ?

Necrotic tissue

9

Epithelialization is in the ?

Epidermis

10

cells
migrating across
wound surface;
color could range from glass to pink

Epithelialization

11

buildup of tissue that
inhibits
epithelialization (when granulation tissue
exceeds skin height)

Hypergranulation

12

Assess wound drainage amount

Minimal
Light
Moderate heavy

13

4 types of wound drainage

Serous
Serosangineous
Sangineous
Purulent

14

clear or light-yellow plasma

Serous type of drainage

15

Pink to light red plasma wound drain

Serosangineous

16

Red with fresh blood wound drain

Sangineous

17

Thick drainage, creamy yellow, green, white or tan = infection

Purulent type of drainage

18

What is a maceration type of wound?

Too much moisture; over hydrated wound edges

19

What’s it called when the edge of the wound is rolled under

Epibole

20

Best way to determine infection is with a ?

Wound culture

21

One symptom of wound infection is delayed healing

Greater than 4 weeks

22

What scale is used to assess pain

VAS or face scale

23

What is the Braden scale

Predicts pressure sore risk

24

Highest and lowest possible score for Braden scale

23 and 6

25

Less than 9 for Braden scale is

Very high

26

PUSH stands for

Pressure ulcer scale for healing

27

PUSH does what?

Monitors healing over time

28

Normal WBC

4500 to 11,000 mm3

29

Low WBC

Leuokopenia

30

High WBC

Leukocytosis

31

Normal RBC for men

4.7 to 6.1 million /ml

32

Normal hematocrit for men

42-52%

33

Normal hemoglobin for men

14 - 18 g/dL

34

Normal RBC for women

4.2 - 5.4 million/mL

35

Normal hematocrit for women

37 - 47%

36

Normal hemoglobin for women

12 - 16 g/dL

37

Normal RBC lab value

150,000 to 400,000 / mL

38

Elevated RBCs

Thrombocytosis

39

Deficiency of RBCs

Thrombocytopenia

40

What is prothrombin time?

Time it takes plasma to clot after addition of tissue factor

41

Normal prothrombin time

12 - 15 seconds

42

Prothrombin time is how many times higher for patients with hypercoagulability?

1.5 to 2.5 times higher

43

If PT is more than 2.5x normal what happens?

Spontaneous risk for bleeding

44

What’s normal PTT?

25 - 40 seconds

45

Normal INR

0.9 to 1.1

46

Measures intrinsic and common coagulation
pathways

PTT

47

Na+ electrolytes that influences swelling

135 - 145 mEq/L

48

K+ electrolytes

3.5 - 5

49

Hyper or hypokalemia can cause?

Arrhythmias

50

Cl-

98 - 109

51

HCO3 electrolyte

20-30

52

BUn is an indicator of?

Renal function and fluid status

53

Normal BUN

8 - 25 mg/dL

54

Elevated levels of urea associated with

Delayed wound healing

55

Normal creatinine

0.6 - 1.4 mg/dL

56

If BUN increases while creatinine decreases, indicates ?

Dehydration

57

Normal Hgb A1C

Less than 6.1%

58

Glucose when fasting

Less than 110 mg/dL