Wound Assessment Flashcards
(38 cards)
what is the periwound
the tissue surrounding the wound itself. This tissue ideally provides a barrier to the wound, which protects it and confines the area of healing, ideally, so that the wound does not spread
what is involved in the observation process of the periwound
Texture – Scar Tissue – Callus – Maceration – Edema – Color – Temperature – Hair distribution – Nails – Blisters – Sensation- pain, thermal, touch
what is skin turgor
sign commonly used by health care workers to assess the degree of fluid loss or dehydration
dry skin is caused by
atrophy of epithelial and fatty layers in the dermis and also a decrease in sebaceous gland secretions
loss of elasticity is due to
shrinkage of collagen and elastin
how do skin tears occur
from weakening of the juncture between the dermis and epidermis
why does a loss of sweat cause an increase in infection
a loss of sweat changes the Ph of the skin which results in increased likelihood of infection
what is the role of a callus
protective function against shearing from bone on a surface
what is maceration
softening of the tissues with fluid
what can cause maceration
– Perspiration – Soaking in tub – Wound exudate – Incontinence – Wound dressings
what is released when there is edema present
histamines
Pitting Scale
1+ Trace Barely perceptible depression 2+ Mild Easily identified depression, skin rebounds in < 15 seconds 3+ Mod Rebounds 15-30 seconds 4+ Severe Rebounds > 30 seconds
what does it mean if the color is blanchable
changes momentarily with light pressure
if it is unblanchable?
color doesn’t change with light pressure
how would you assess pain?
Pain questionnaires – Pain scale – Pain diary – Medications – Sleeping history
what is the best predictor of protective sensation
semmes-weinstein monofilaments: 5.07 (10-g)
patients with what type of co-morbidity would need a monofilament
someone with diabetes or PVD
examination of hair distribution
Check great toe
– Move proximally from the ankle and note
where hair loss starts
– Palpate skin temperature and pulses in this
area
what are you looking for when examining the nails
Color – thickness, – Shape – Irregularities – Ingrown – fungus
what are blisters
trauma to epidermis
– nature’s best dressing
what does it mean if a blister has clear fluid
likely epidermis only
what does it mean if a blister is bloody, brown or cloudy
may involve the dermis
what does it mean when you press down on a blister and it bounces back
it is mildy congested
what does it mean when you press down on a blister and it is boggy, soft or spongy
necrosis has occurred
