2] Wound Assessment Flashcards
(58 cards)
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
Diagnoses that are risk factors
Diabetes Plegias Urinary incontinence or chronic bowel Sepsis Terminal illness C-diff Immobile Hip surgery
Measure wounds in ?
Cm
What is undermining
Open skin at the surface caused by shearing
Documentation of measure of a wound tunneling and undermining
Undermining from 3:00 - 7:00 with depth of 1.5 cm at 7:00
passageway belowsurface of skin in
any direction from
surface or edge of
wound
Tunneling
thick, leathery, necrotic, devitalized
tissue
Eschar
Slough is ?
Necrotic tissue
Epithelialization is in the ?
Epidermis
cells
migrating across
wound surface;
color could range from glass to pink
Epithelialization
buildup of tissue that
inhibits
epithelialization (when granulation tissue
exceeds skin height)
Hypergranulation
Assess wound drainage amount
Minimal
Light
Moderate heavy
4 types of wound drainage
Serous
Serosangineous
Sangineous
Purulent
clear or light-yellow plasma
Serous type of drainage
Pink to light red plasma wound drain
Serosangineous
Red with fresh blood wound drain
Sangineous
Thick drainage, creamy yellow, green, white or tan = infection
Purulent type of drainage
What is a maceration type of wound?
Too much moisture; over hydrated wound edges
What’s it called when the edge of the wound is rolled under
Epibole
Best way to determine infection is with a ?
Wound culture
One symptom of wound infection is delayed healing
Greater than 4 weeks
What scale is used to assess pain
VAS or face scale
What is the Braden scale
Predicts pressure sore risk
Highest and lowest possible score for Braden scale
23 and 6
