S1L1: Wound Assessment Flashcards
(110 cards)
1
Q
Partial thickness vs. Full thickness
Destruction of both the
epidermis and dermis
A
Partial Thickness
2
Q
Partial thickness vs. Full thickness
Pink, painful, NO yellow tissue
A
Partial Thickness
3
Q
Partial thickness vs. Full thickness
Destruction of the dermis, epidermis, and
subcutaneous tissue
A
Full Thickness
4
Q
Partial thickness vs. Full thickness
May expose the muscles and bones
A
Full thickness
5
Q
Acute vs. Chronic Wounds
An injury to the skin that occurs suddenly
rather than over time
A
Acute
6
Q
Acute vs. Chronic Wounds
It heals at the predictable and expected rate
of the normal wound healing process
A
Acute Wound
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
8
Q
Acute vs. Chronic Wounds
Less than 12 weeks
A
Acute Wound
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
10
Q
Acute vs. Chronic Wounds
Slow to heal are often = ___ (>12 weeks)
A
Chronic Wound
11
Q
Acute vs. Chronic Wounds
Stuck in one or more of the phases of wound
healing
A
Chronic Wound
12
Q
Acute vs. Chronic Wounds
often remain in the inflammatory stage for too long
A
Chronic Wound
13
Q
Acute vs. Chronic Wounds
Venous and arterial ulcers, diabetic ulcers,
and pressure ulcers are only a few examples
A
Chronic Wound
14
Q
Acute vs. Chronic Wounds
Cause patients severe emotional and physical
stress and pain
A
Chronic Wound
15
Q
Wound size in documented in ___
(Length x width x depth)
A
centimeters
16
Q
Bottom of the wound (deepest)
A
Wound base
17
Q
Vertical distance from the visible surface to
the deepest area
A
Wound depth
18
Q
Inside the perimeter of the wound
A
Wound Edges/Margins
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
20
Q
○ Rolled edge
○ Wound edge curled under, preventing wound closure
A
Epibole
21
Q
How to document epibole?
A
(+) Epibole on __
22
Q
○ Fibrotic, hyper-keratotic
■ an excess in production of skin
○ Constantly exposed to repeated injuries
A
Callused
23
Q
○ Skin surrounding the wound
○ Color should be noted
A
Periwound Area
24
Q
Periwound Area
Minimum of __ cm
A
4 cm
25
Periwound Area Color:
Infection, trauma, inflammation
Red
26
Periwound Area Color:
Moisture (maceration)
White
27
Periwound Area Color:
Poor blood flow, trauma
Blue/Purple
28
Temperature:
Possible infection in the area
Warm
29
Temperature:
Poor blood flow in the area
Cold
30
How to document Periwound Temperature?
(+) hyperthermia/hypothermia periwound area of _____________
31
Periwound texture can be
(1) Moist
(2) Macerated/Boggy (Soft/Mushy)
How do you document it?
(+) maceration on periwound area on ___
(+) boggy periwound area on ________
32
o Abnormal hardening of tissue
o Caused by consolidation of edema
o May be a sign of underlying infection
Wound Induration
33
Maceration is _____ while Induration is _____
Maceration - soft and boggy to touch
Induration - firm/hard (really swollen)
34
Loss of epidermis, caused by exposure to urine,
feces, body fluids, wound exudate or friction
Denuded
35
T/F: Maceration and denuded can be interchangeable but usually maceration occurs initially then progresses to
denudation
True
36
Loss of epidermis
Erosion
37
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
True
38
○ Linear erosion
■ Loss of epidermis
○ Destruction of skin by mechanical means
○ Scratch
Excoriated
39
Can be caused by allergic reaction or prolonged exposure
Rashes
40
Channel or pathway that extends in any direction from the wound through the subcutaneous tissue
Tunneling
41
Tissue destruction underlying intact skin along the wound margins
Undermining
42
T/F: Tunneling is caused by shearing or friction on the area
False: Undermining
43
Non-viable Tissue (dead)
Has NO blood flow
Necrotic Tissue
44
T/F: Necrotic tissue is Better off removed because it impedes wound healing ALWAYS
False: not all the time because eschar is sometimes left to help the wound heals
45
Types of Non-viable Tissue:
o yellow, green, grey
o lighter, thin, wet
o stringy
Slough
46
Types of Non-viable Tissue:
o black, brown, grey
o darker, thicker
o harder
Eschar
47
T/F: Eschar, slough and granulation could co-exist at
the same time
True
48
Regeneration of the epidermis across a wound surface.
Epithelialization
49
T/F: The epithelial wound edge is continuous and often difficult to see.
True
50
Epithelial tissue is the outermost layer of the skin. What is its color?
Deep pink to pearly pink
51
T/F: Epithelialization is a bad sign
False: Closure of the wound, healing
52
● New tissue that replaces dead tissue
● Beefy, red color
● Puffy & mounded
Granulation Tissue
53
Granulation Tissue grows from __ of the wound
Base
54
○ Forms above the surface of the wound
○ Delays epithelialization
Hypergranulation Tissue
55
○ Pink to dark red
○ Highly vascularized
○ Striated, grooved, or ridged
Muscle tissue
56
Tendon Attaches muscle to bone. It is ____ when healthy
Shiny
57
● Hypodermal area
● Covering over the muscles
● Shiny & white
● Great organizer
Fascia
58
● Shiny & smooth, White in color
Bone
59
WOUND BASE COLOR
Healthy tissue,
Good blood flow
Beefy Red
60
WOUND BASE COLOR
Poor blood flow,
Anemia
Pale Pink
61
WOUND BASE COLOR
Engorged, swelling, high bacteria levels (infection), trauma (exposed to repetitive trauma)
Purple
62
WOUND BASE COLOR
Non-viable, necrotic tissue
Black/Brown
63
WOUND BASE COLOR
Non-viable tissue, slough
Yellow
64
WOUND BASE COLOR
Non-viable tissue, active infection
○ Similar to the color of phlegm
Green
65
WOUND BASE COLOR
○ Macerated, poor blood flow
White
66
T/F: WOUND BASE COLOR Would dictate if wound is healing properly
True
67
How to document EXUDATE (DRAINAGE)?
Documented by type & amount (approximate)
○ (+) yellow exudate on wound, ~1 tsp on ___
68
TYPES OF EXUDATES
Thin clear watery plasma
Serous
69
TYPES OF EXUDATE
Red or bloody
Sanguinous
70
TYPES OF EXUDATE
Thin, watery, pale red to pink, plasma with RBC
Serosanguinous
71
TYPES OF EXUDATE
Thick, opaque tan, brown color
Purulent
72
TYPES OF EXUDATE
COLOR: Clear straw colored
Serous
73
TYPES OF EXUDATE
COLOR: Cloudy
Fibrinous
74
TYPES OF EXUDATE
COLOR: Red
Sanguinous
75
TYPES OF EXUDATE
COLOR:Murky yellow/ Cream/ Coffee
Seropurulent
76
TYPES OF EXUDATE
COLOR: Yellow/grey/brighter green
Purulent
77
TYPES OF EXUDATE
COLOR: Dark, Blood-stained
Haemopurulent
78
TYPES OF EXUDATE
COLOR: Dark red
Hemorrhagic
79
TYPES OF EXUDATE
COLOR: Opaque/ Pink
Serosanguinous
80
TYPES OF EXUDATE
CONSISTENCY: Viscous / stick
Haemopurulent
81
TYPES OF EXUDATE
CONSISTENCY: Thicker / sticky / creamy
Seropurulent
82
TYPES OF EXUDATE
CONSISTENCY: Thin watery
Serous
Fibrinous
Serosanguinous
Sanguinous
83
TYPES OF EXUDATE
CONSISTENCY: Thick / sticky
Hemorrhagic
Purulent
84
TYPES OF EXUDATE
SIGNIFICANCE: Normal
Serous
85
TYPES OF EXUDATE
SIGNIFICANCE: May indicate fibrin strands present. This is normal
Fibrinous
86
TYPES OF EXUDATE
SIGNIFICANCE: May indicate the presence of red blood cells and capillary damage from, e.g. traumatic dressing removal or surgery
Serosanguinous
87
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
Sanguinous
88
TYPES OF EXUDATE
SIGNIFICANCE: May indicate a bacterial infection and/ presence of necrotic liquid / tissue
Seropurulent
89
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
Purulent
90
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.
Haemopurulent
91
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.
Hemorrhagic
92
AMOUNT OF EXUDATE
Wound tissues are very moist
Drainage < 25% of bandage is covered by the exudate
SMALL / MINIMAL
93
AMOUNT OF EXUDATE
Wound tissues wet
Drainage occupies 25-75% of
bandage
Moderate
94
AMOUNT OF EXUDATE
Tissues filled with fluid
Drainage: > 75% of bandage
Large / Copious
95
EDEMA GRADING
Indentation is barely detectable
1+
96
EDEMA GRADING
Slight indentation is visible when skin is depressed,
returns to normal in 15 seconds
2+
97
EDEMA GRADING
Deeper indentation occurs when pressed and
returns to normal within 30 seconds
3+
98
EDEMA GRADING
Indentation lasts for more than 30 seconds
4+
99
PULSE QUALITY
no pulse
0
100
PULSE QUALITY
weak pulse, difficult to palpate
1+
101
PULSE QUALITY
Palpable but not normal, diminished
2+
102
PULSE QUALITY
Normal, easy to palpate
3+
103
PULSE QUALITY
Bounding, very strong, may imply the possibility of an aneurysm or other pathological conditions
4+
104
○ 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,
RISK Assessment Tools
105
Assessment and documentation should be done at least ____!
Weekly
Note: More frequent if with complications and changes in wound characteristics
106
T/F: Documenting wound assessment includes:
○ Size
○ Location
○ Tissue types
○ Exudate
○ Odor
○ Surrounding tissue (periwound area)
○ Pain
True
107
help maintain turning schedules to reduce pressure injuries. Pillows can also be used.
Body positioning wedges
108
cushion foot and suspend heel to relieve pressure while reducing skin trauma. This can also be worn by pts with existing wounds.
Heel protectors
109
help protect fragile skin from skin tears, bruising, and friction. If the skin already has an issue, it can protect from further injury.
Skin sleeves
110
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.
Contracture Braces
