Week 3: Examination of Patients with Open Wounds Flashcards Preview

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Flashcards in Week 3: Examination of Patients with Open Wounds Deck (70):
1

What are some things that should be assessed during a cardiovascular/pulmonary systems review?

heart rate, blood pressure, respiratory rate, edema, pulse oximetry

2

What are some things that should be assessed during a musculoskeletal systems review?

structure, posture, ROM, strength

3

What are some things that should be assessed during a neuromuscular systems review?

balance, gait, mobility, transfers

4

What are some things that should be assessed during a gastrointestinal systems review?

nutrition intake, supplementation, continence, BMI

5

What are some nutritional assessment screening tools?

Rapid Eating and Activity Assessment for Patients (REAP)
Weight, Activity, Variety, Excess (WAVE)

6

What are some things that should be assessed during a urogenital systems review?

incontinence, poorly controlled diabetes, UTIs

7

______ is one of the leading causes of skin breakdown?

Incontinence

8

What are some things that should be assessed during an integumentary systems review?

skin integrity, skin color, scar formation, hair and nail growth

9

What is the ability of skin to return to its original shape/condition?

turgor

10

What are some routine integumentary tests and measures?

integumentary integrity, circulation (capillary refill), and sensory integrity (monofiliament)

11

What is the likely cause of a wound on a bony prominence?

pressure

12

What is the likely cause of a wound on a fold of skin?

friction, moisture

13

What is the likely cause of a wound on toes?

friction, decreased microcirculation

14

What is the likely cause of a wound on the bottom of the foot?

trauma, pressure

15

What is the likely cause of a wound on the shin or calf?

trauma, decreased circulation

16

What is the likely cause of a wound with round or elliptical edges?

pressure

17

What is the likely cause of a wound with jagged edges?

shear or friction

18

What is the likely cause of a wound with irregular shape?

vascular

19

What is the likely cause of a wound with a linear shape?

trauma or friction

20

What is the wound?

considered to be the open area only

21

What is the wound base?

the bottom of the wound (wound bed)

22

What is the wound depth?

vertical distance from the visible surface to the deepest area in the wound bed

23

What are the wound edges/margins?

inside perimeter of the wound (where epibole occurs)

24

What is the periwound area?

minimum of 4 cm surrounding the wound

25

What is a channel or pathway that extends in any direction from the wound through the subcutaneous tissue or muscle, creating dead space with the potential for abcess formation?

tunneling

26

What is tissue destruction underlying intact skin along the wound margins, the base of the wound is larger than the skin surface?

undermining

27

tunneling involves a ____ portion of the wound ege and undermining involves a ____ portion.

tunneling, undermining

28

What are tunneling and undermining caused by?

shearing forces on a wound

29

How is a wound measured via direct measurement?

measure the longest length and the widest width

30

Wound surface area =

L x W x D in cm

31

What are the cons of linear measurement?

cannot accurately determine depth if wound is covered with nonviable tissue, does not include consideration of periwound area

32

How is wound tracing performed?

two-layered transparent film

33

What are the advantages of wound tracing?

more accurate representation of wound size and shape, allows for future comparison

34

What are some cons of wound tracing?

may be difficult to visualize wound perimeter through transparency

35

What are some advantages of photographic measurement?

digital images are high quality, avoids contact with patient wound, provides periwound and wound bed characteristics, nice adjunct

36

What are some cons of photographic measurement?

angle and focal distance can influence size, can be manipulated, lighting need specific wound care camera

37

How is volumetric measurement done?

with dental, silicone molding, or saline filling

38

What are the cons of volumetric measurement?

time consuming and painful, detrimental to wound healing

39

When is total body surface area wound measurement performed?

large surface area wounds, burns

40

What is another name for tunneling?

sinus tract

41

Tunneling and undermining are common in which kinds of patients?

neuropathic ulcerations and surgical wounds

42

What aspect of wound beds do you look at?

partial or full thickness, granulation tissue, nectrotic tissue, or other structures (fascia, muscle, tendon, bone, foreign bodies or debris)

43

What is pink-red tissue with small buds?

granulation tissue

44

What is purple tissue?

may indicate infection

45

What is yellow, fibrous slimy green nonviable tissue?

slough

46

What is black, no longer wet, dead tissue?

escar

47

What aspects of wound edges do you look at?

distinctness, thickness, color, attachment to base, evidence of epithelialization, scarring, and pigment changes

48

What aspects of wound drainage do you look at?

type, color, consistency, amount

49

What does serous drainage indicate?

normal

50

What does sanguinous drainage indicate?

normal acutely or in response to trauma

51

What does serosansuinous drainage indicate?

normal

52

What does purulent drainage indicate?

possible infection

53

What seropurulent drainage indicate?

possible infection

54

What does clear drainage indicate?

normal

55

What does pale yellow drainage indicate?

normal

56

What does red drainage indicate?

fresh blood

57

What does dark brown drainage indicate?

dried blood

58

What does blue-green drainage indicate?

possible pseudomonas infection

59

What does thin, watery drainage indicate?

normal

60

What does thick drainage indicate?

possible infection

61

What does no drainage indicate?

dessicated wound bed

62

What does minimal or moderate drainage indicate?

normal (within proportion)

63

What does copious drainage indicate?

possible infection

64

What periwound characteristics do you look for?

structure and quality, color, epithelial appendages, edema, temperature

65

What is the classification of pitting edema?

1+ - 4 +

66

What is 1+ edema?

barely perceptible depression

67

What is 2+ edema?

easily identifiable depression, rebounds in

68

What is 3+ edema?

depression rebounds in 15-30 secs 5-7 mm

69

What is 4+ edema?

depression lasts > 30 secs > 7mm

70

Where are the most common places to test for edema?

lateral malleolus, mid tibia