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Flashcards in Wound Assessment/Treatment Deck (12):
1

Things to include in wound assessment

-ROM
-Sensation
-Strength
-Functional mobility (bed mob, transfers, gait)
-neuromuscular coordination
-balance
-equipment used

2

Examination of skin

-observation
-characteristics of lesion
-location/distribution of lesion
-pattern/arrangement of lesion
-exudates present

3

Size and Level of Tissue Involvement

-Area: length x width=cm squared
-Depth: cm from wound bed to skin surface

4

Length vs Width

length: 12:00-6:00 clock
Width: 9:00-3:00

5

Wound Surface

-color
-tissue type (slough, necrotic, granulation etc)
-exudate amount
-exudate type
-undermining

6

Surrounding Surface

-skin color
-erythema of intact skin
-tissue edema
-tissue induration

7

Treatment Options

-US, hydrotherapy, pulsed lavage, hyperbaric O2, Estim, compression, UV, debridement, dressings/bandages

8

Add functional component to wound goals

-"to be able to wear shoes in community"
-"promote independence with self care"

9

Intervention of Necrotic Tissue

-debridement
-many types

10

Types of Debridement

-non-selective
-selective
-enzymatic debridement
-autolytic
-biosurgical
-surgical

11

Normal Hemoglobin A1c

6.5 or less

12

Hb A1c

-measure blood sugar over time (30-60 days)
-glucose sticks to blood