Week 6 Wound Exams and Assessments Flashcards

Question

If the consistency of the drainage is thick this means?

Answer 1

Possible infection

Answer 2

it can occur in deeper wounds that are more defined edges and margins

Answer 3

It is not clearly defined edges

Answer 4

Attached wounds tend to heal quicker

Answer 5

Epiboly Hyperkeratotic (callus) - Epiboly is a rolled edge in a crater type wound, keratinocytes migrate down instead of across which they then think they are finished healing the wound; they only made the edges thicker and left the wound open/stagnant/unhealed

Answer 6

1+ = Barley perceptible depression : <2mm 2+ = Easily identifiable depression, rebounds <15 seconds : 2-4mm 3+ = depression rebounds 15-30 seconds : 5-7mm 4+ = depression lasts >30 seconds : >7mm

Answer 7

waft Sickly sweet= pseudomonas Ammonia like = proteus infection Musky= typical of malignant tissue

Answer 8

- Erythema disproportionate to size of the wound - Poorly defined erythema boarder - Fever - Warmth disproportionate to size of the wound - Could have induration Induration= when the soft tissue of different parts of the body, especially the skin, becomes thicker and harder due to an inflammatory process caused by various triggering factors.

Answer 9

" There are certain interventions which require immediate and continuous examination and evaluation throughout the intervention and are thus beyond the scope of a PTA

Answer 10

- Allowed to follow Plan of Care and treatment - Can conduct objective tests to measure goals -Can measure wounds - describe wounds; color, drainage, odor, wound bed, periwound, ect - Circumferential measurements

Answer 11

Stage 1= only epidermal damage can be noted visibly, although tissue biopsies may show tissue damage extending below epidermis : Non-blanchable erythema of intact skin; area may be painful, warmer, cooler, firmer and softer compared to adjacent area Stage 2= partial thickness ulcer involving the epidermis, dermis, or both; NO ADIPOSE OR DEEPER TISSUES ARE VISBLE Stage 3= Full thickness skin loss involving the epidermis, dermis, and subcutaneous tissue. ( BONE, TENDON, LIGAMENTS, MUSCLE ARE NOT VISBLE OR PALABLE) Stage 4= Full thickness skin loss involving the epidermis, dermis, subcutaneous tissue, fascia and underlying structures such as MUSCLE, TENDON, JOINT CAPSULE, LIGAMENT, CARTLIAGE OR BONE ARE VISBLE (CORE 4) Unstageable= Full thickness; once devitalized tissue is removed the wound will be a stage 3 or 4

Answer 12

This test is used for predicating Ulcer development <18 = at risk 15-18 = mild risk 13-14= moderate risk <13 high risk Look up chart to understand how it is counted

Answer 13

Used for Neuropathic Ulcers Grade 0= No open lesion; may have deformity or cellulitis; Superficial or partial thickness Grade 1= Superficial ulcer; partial or full thickness Grade 2= Deep ulcer to tendon, capsule, or bone; Full thickness Grade 3= Deep ulcer with abscess, osteomyelitis or joint sepsis; full thickness Grade 4= Localized gangrene; full thickness Grade 5= gangrene of the entire foot; Full thickness

Answer 14

4.17= Decreased sensation; produced 1g of pressure 5.07= loss of protective sensation; produced 10g of pressure 6.10= Absent sensation; produced 75g of pressure

Answer 15

- Position: primarily LE, distal toes, dorsum of the foot, areas of trauma - Little to no drainage - Periwound/Extrinsic Tissue: thin, shiny, anhydrous skin, loss of hair, thickened yellow nails, pale dusky or cyanotic skin, edema is unusual -Temperature; Cool or decreased - Pulse; Decreased or absent pedal pulse - Wound characteristics; Begin, small/shallow, round and regular shaped to conform to trauma, any granulation tissue will be pale/grey, necrotic tissue desiccated with black eschar - This is from a lack of blood flow to to LE, trauma, acute embolism, diabetes mellitus, RA, Arteriosclerosis, atherosclerosis

Answer 16

Commonly caused by venous hypertension causing the calf pump to fail, vein dysfunction, bicuspid valves fail to close -Position= Medial leg, medial malleolus, areas of trauma -Presentation= irregular shaped, fibrous, glossy coating, red, ruddy wound bed, copious amounts of drainage -Periwound/Extrinsic tissue= edema, dermatitis/cellulitis, hemosiderin staining, lipodermatosclerosis - Temperature= Normal to mild warm

Answer 17

- Localized area of necrosis that develops when compressed between firm surfaces like a paraplegic sitting in a chair for hours a day without moving can cause him to get pressure injuries on their ischial tuberosities -Position= over bony prominences, areas of outside pressure - Presentation= description from NPUAP Periwound/Extrinsic Tissue= Surrounded by a ring of erythema, localized warmth, fibrous and induration, dermatitis common, -Temperature= increased in areas of hyperemia, decreased in areas of necrosis(necrotic) - Wound characteristics= typically range from non-blanchable erythema of intact skin to full thickness destruction --> deeper ulcers have exposed tendon, muscle, capsule and or bone -->tunneling, undermining common --> unless previously debrided a necrotic base is normal

Answer 18

Can happen from diabetes, vascular diseases -Position= plantar aspect of the foot, midfoot with charco foot deformity, forefoot under calluses, heel friction areas, dorsal/or tips of toes if clawed, medial 1st and lateral 5th MTPJ - Presentation= Rounded, punched out, callused rim, minimal drainage unless infected, eshcar or necrotic base uncommon - Periwound/extrinsic Tissue= Dry, cracked skin, callus, foot structural deformities - Temperature= normal or increased - Pulse= normal or accentuated (people with diabetes may have an abnormal ABI/bounding pulse)

Week 6 Wound Exams and Assessments Flashcards

(42 cards)