Chapter 4 - Examination of Open Wounds Flashcards
Normal serum albumin
3.5 - 5.5
low = malnourished
high = dehydrated
Normal WBC count
4500 - 11,000
Hemoglobin
Women = 12-16 Men = 14-18
Platelet
150,000-400,000
Hematocrit
Women = 38-46 Men = 42-54
Total lymphocyte count
> 1800
Total RBC count
women = 4-5 men = 4.5-6.2
Serum prealbumin
16-40
Serum transferrin
> 170
Blood glucose
70-110
BUN
8-20
Creatine
.8-1.2
Cardiovascular/Pulmonary Systems Review
HR, BP, RR, edema, pulse ox
Musculoskeletal Systems Review
structure, posture, ROM, strength
Neuromuscular Systems Review
gait, mobility, transfers, balance
GI Systems Review
nutrition, supplementation, continence, BMI, REAP/WAVE nutritional assessment screening tools
Urogenital Systems Review
incontinence, poorly controlled diabetes, UTI
Integumentary Systems Review
skin integrity, color, scar formation, hair and nail growth
Wound Characteristics
Location Size Tunneling/Undermining Wound Bed Wound Edges Wound Drainage Wound Odor
Periwound Characteristics
Structure/Quality Color Epithelial appendages Edema Temperature
Wound bed characteristics
color, consistency, adherence, amount
Wound edge characteristics
distinctness, thickness, color, attachment to base of wound, evidence of epithelialization/scarring/pigment changes
Wound drainage characteristics
type, color, consistency, amount
Pitting Edema Classification
1+ = 7, >30 sec