WOUND CARE ASSESSMENT Flashcards
(33 cards)
What should be inspected?
Color, Turgor, Edema, Lesion, Associated injuries
What will be assessed in wounds?
Location, Width/Length/Depth, Last Tetanus Shot, Appearance
Wound appearance are?
Size, Draining, swelling, pain
Types of tissues?
Necrotic, Eschar, Slough, Granulation
Necrotic tissue is?
Inviable
Eschar tissue is?
Color black or brown with leathery texture
Slough tissue is?
Stringy, cheesy, loose, yellow, tan
Granulation tissue is?
Viable pink pale to beefy red
What is epithelialization?
Occurs along wound edges with pale pink appearance of the wound
Periwound areas checked?
Erythema, Maceration, Rash
What is Erythema?
Infection redness
What is Rash?
Papular or macular shaped caused by fungal infection
Undermining/Tunneling materials inspection: Descriptor and for measurement
Hand of clock and cotton tipped applicator
Acute care implementation support?
Fluid intake 2,500mL a day
Acute care implementation prevention?
Transmission and contamination
Acute care implementation positioning?
Offload pressure
How to prevent MASD and pressure injuries?
Wrinkle free, semi fowler position, change pos feq, don’t use baby powder/cornstarch
How to treat wounds? 5 steps
Surgical asepsis
Never use alcohol or hydrogen perox
Obtain c and s
Teach pt
Teach pt of ROM
How to treat pressure injuries using the RYB CODE?
Red: protect, Yellow: Cleanse, Black: Debride
Transparent film dressing
Ulcerated, Burned area
Hydrocolloid dressing
Pressure injuries
Dressing wounds? 2
Secure and suture/staples
Cleaning wounds? 4 steps
Remove debris, Saline solu, not all need to be changed, penrose drain (surgical)
Pressure should be between psi?
4-15 psi
