Lab 1&2: wound assessment Flashcards
(37 cards)
1
Q
Arteral wound
location:
tissue:
Pain:
skin:
exudate:
A
- location: Distal digits (toes or fingers)
- tissue: Dry, necrotic or slough little or no granulation
- Pain: yes, may have dependent leg syndrome or rest pain
- skin: dry, hairless, shiny, thin, postive rubor of dependcy
- exudate: none unless infected due to blood not getting to tissue
2
Q
Venous wound
location:
tissue:
Pain:
skin:
exudate:
A
- location: lower 1/3 of leg (called gaiter area)
- tissue: red or pink, bark texture, yellow slough poor granulation
- Pain: generally no painful unless vasculitic or infected
- skin: hemosiderous staining, atrophie blanche
- exudate: varies may have copious serous drainage
3
Q
Pressure wounds
location:
tissue:
Pain:
skin:
exudate:
A
- location: over bony prominences
- tissue: varies from non-blanchable erythema to dark red to eschar (dying tissue)
- Pain: varies depending on the structures involved
- skin: discolored from erythematous to hypoxic may be macerated or excoriated
- exudate: varies, depending on infection
4
Q
Neuropathic wounds
location:
tissue:
Pain:
skin:
exudate:
A
- location: weight-bearing surface of the foot or dorsal digits (also arterial dysfunction)
- tissue: callus or blister, slough, may probe to bone, nectrotic with PAD
- Pain: none until infected then deep throbbing (didnt feel injury)
- skin: dry, thickness, scaly, hyperkeratotic
- exudate: varies depending on infeciton
5
Q
Subjective interview for wounds
A
- when and how did the wound begin
- precipitating events
- previous treatments
- other signs and symptoms
- describe the pain/quantity and quality/alleviating or precipitating factors
- comorbidities
- meds and allergies
- nutritional status
- alcohol, drug, tobacco use
- physical activity level
- assistive devices/shoes
- patient goals
6
Q
Melanoma
A
- a tumor of the melanocytes of the epidermis
- common cause is exposure to UV sunlight or tanning beds
- early melanomas are highly treatable
- our role is in referral if we note any abnormal skin lesion
- first line of treatment is excision of the tissue involved
- ABCDE
7
Q
Skin assessment: what to think about
A
- good lighting
- patient position
- modesty and comfort
- adequate exposure of the wound and surrounding tissue
- observe initial appearance and then after cleaning
8
Q
Describe wound location
A
- aids in determining wound etiology
- described by anatomical body part using medical terminology
- BE SPECIFIC
- want to be able to say where
- could measure from bony landmark
9
Q
2 methods to measure surface area: length x width use metric
A
- clock method
- perpendicular method
10
Q
Depth
A
- used for volume measurement
- if slough or necrotic tissue covers the wound, state “unable to determine”
- if depth is minimal state as 0.1
11
Q
Wound tracing
A
- before placing the tracing guide on the wound, a clear plastic film is placed on the wound to prevent fluids from getting on the tracing
- the tracing guide is placed over the first layer of plastic filme and wound is traced with an indelible marking pen
- recommended for serpentine wounds that do not have well-defined lenghts and widths
12
Q
Undermining
A
- disrupted attachment of the skin to the tissue below
- probe horizontally underneath edges
this will not heal
13
Q
tunneling/sinus tract
A
- wound extensions that usually run through tissue or along fascial places
- sinuses are not considered deepest depth for volume measurement
- sinuses: extensions that run along fascial plane and may contain fluid trapped in the deeper area
- tunneling occurs when two cutaneous wounds connect
14
Q
tissue types
eschar/nectrotic
A
- may be black, brown, yellow, tan
- bad/not viable tissue
- if its on a heal usually left there
15
Q
tissue types
slough
A
- usually soft, yellow and adherent
- need to take off to look for wound healing
16
Q
tisssue types
granulation tissue
A
- with epithelialized edges
- good viable healing tissue
17
Q
tissue types
hypergranulation
A
- not good
exceeds boarders of wound
18
Q
wound edges
arterial
A
- punched out edges
- regular edges
19
Q
wound edges
venous
A
- more irregular edges
20
Q
wound edges
hyperkeratotic edges
A
- callus
21
Q
wound edges
epibole
A
- rolled edges
- rolled under
- will not get epithelialization
- cells cannot gain ground across the wound bed
22
Q
drainage
scant
A
- barely any drainage visible on the side of the dressing next to the wound
- none visible after dressing removal
23
Q
drainage
minimum
A
- drainage visible on the inner side of the dressing only
- may be some visible on the wound bed after dressing removal
- no new drainage expressed during treatment
24
Q
drainage
moderate
A
- drainage visible on the inner side and small amount on the outer side of the dressing
- some drainage visible on the wound bed after dressing removal
- some drainage occuring during prolonged treatments
25
# drainage
heavy
- drainage visible on both the inner side and outer side of the dressing
- drainage visible immediately after dressing removal and after wound cleansing
- may continue throughout treatment
26
# drainage
copious
- drainage not contained by a dressing deemed appropriate for the wound
- drainage continues throughout the treatment requiring continuous cleansing, suctioning or in the case of bleeding, pressure or thrombotic applications
27
# drainage
serous
- clear/yellow
- watery
- normal during inflammatory stage
- may also be called exudate or transudate
28
# drainage
sanguineous
- thin
- bloody
29
# drainage
serosanguineous
- pink
- watery
- indicates some bleeding
30
# drainage
purulence
- thick
- odiferous
- pus
- large amounts of debris and bacteria
- infection
31
# drainage
seropurulence
- combination of purulent drainage and serous fluid
- can indicate infection that is beginning or ending
- check for smell = infection (odor after cleaning = infection)
- signs of infection: erthema, pain, edema, heat, purulence, malaise, tissue biospy: presence of bacteria >100,000 CFU
32
what to assess of periwound
- erythema: note that darker skinned persons show colors as deepening of normal skin
- cyanosis
- macerated/dessicated
- induration/fibrosis
- excoriation (itchy/scratch)
- hemosiderin staining
- blanched
- ecchymotic
- discolored
- shiny
33
surgical wounds documentation
- location
- surface area
- document closure method/count staples/sutures
- describe tissues, drainage, and periwound
- scab vs eschar
34
tools for measurement of healing
- many specific measurement tools exist
- assess multiple characteristics to monitor and measure healing
- standardized measurement tools are chosen based on validity, reliablity, responsiveness, clinical practicality
35
Bates-jensen wound assessment
- unlike some tools that are specific to a type of wound, this can be used to assess all types of wounds
- 13 sections that are scored on a 1-5 scale (lower score = healthier wound)
- provides an overall score
- provides a nice set of instructions and overall descriptions
- allows for tracking of wound regeneration/degeneration in a consistent
36
healing rates: are the chosen inertventions working?
- healing rates should not be used to predict date of healing
- rates used to help with clinical decision making and identify effective and ineffective treatments
- rate of 30-50% in 2-4 weeks predicts healing
- larger ulcers take longer to heal (size matters)
- moderate arterial insufficiency increases risk of delay oxygen matters
- full thickness ulcers with proper nutrition heal fast - nutrition matters
37
when to reassess
- every 2 weeks
- if after 2-4 weeks of treatment indictaes wound failed to improve or deteriorated...plan of care needs to be modified
- wound to be monitored with each dressing change, may indicate full reassessment needed
