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Practice topics Exam 2 > Wound Management 2 and 3 > Flashcards

Wound Management 2 and 3 Flashcards

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1
Q

Standardized measures

A

There are a lot - esp for pressure ulcers

Difficult to quantify a wound though

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2
Q

Location

A

First thing you need to do

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3
Q

Location - top of foot with hammer toes - you are suspecting

A

Neuropathic foot
Pressure ulcer
Pressure on neuropathic foot is causing the pressure ulcer (if they are ambulating)

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4
Q

Location - venous insufficiency

A

Generally located in the gaiter area

Just above the medial malleolus (no higher than the boots)

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5
Q

Location - wounds in areas that tend to bear pressure - think

A

neuropathic origin - especially in the mobile patient

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6
Q

Size and shape

A

What you look at after location

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7
Q

Size and shape - arterial

A

Defined circular lesion

Looks like punched out

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8
Q

Size and shape - venous ulcer

A

irregular wound margins

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9
Q

Size and shape - most common measurement

A

Linear measures

Finding the longest and the widest points of the wound

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10
Q

Size and shape - documentation

A

Remember to record the direction of the length and width measurements (lateral to medial, or head to foot)

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11
Q

Size and shape - clock method

A

Saying longest is from 10 to 4 oclock and widest is from 1 to 7 oclock

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12
Q

Size and shape - grid

A

Position grid over the wound and then you measure the grid in a variety of diff ways
This is still linear - but now counting the cm squares
Gives you an area concept

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13
Q

Size and shape - Linear measures - pros

A

Fast
Easy
Inexpensive
High intra and inter rater reliability

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14
Q

Size and shape - linear measures - cons

A

May overestimate the size of the wound

Not always indicative of how well a wound is healing

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15
Q

Size and shape - Tracings

A

Used in conjunction with linear measurements

Variety of tools - acetate sheets, plastic bags, special measurement sheets

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16
Q

Size and shape - tracing - pros

A

Fast
Easy
Reliable
Can be retained as part of medical record

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17
Q

Size and shape - Photos - what impacts the image

A 
Distance
Lighting 
Body part position
Still a 2D image of a 3D product 
Special cameras and film are available
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18
Q

Depth

A

3rd dimension of a wound

Distance from the surface of the skin to the deepest portion of the wound bed

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19
Q

Depth - con

A

Reliability is questionable

Undermining, tunnels, or sinus tracts can be a problem with measuring depth

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20
Q

Depth - ways to measure

A

Calibration sticks with markings on the side of it - put it in deepest part
Metal tipped probes
Special rulers
Cotton tipped applicators

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21
Q

Depth - ways to measure - problem with cotton tipped applicators

A

Wound will not heal with foreign materials and these cotton tipped applicators will leave cotton fibers in the wound!

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22
Q

Volume measures

A

Only in wounds without tunnels or significant undermining

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23
Q

Volume measures - how

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A

Place an amount of liquid (sterile solution) into the wound

Use a calibrated syringe and withdraw that fluid and keep track of the amount of fluid added to the wound

24
Q

Volume measures - con

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A

Wound exudate/slough may impede the measurement and clog the syringe

25
Tool for tunneling and undermining measurement
Wound stick tunneler
26
Drainage
In addition to wound itself - make sure you look at the dressing Clean wound and then look to see if wound is producing exudate
27
Drainage - measurement
Can weight dressing and then weigh it again in about 3 days to see how much weight of exudate you have Often will say minimal, moderate, severe for amount
28
Drainage - document what in addition to amount
Consistency Color Odor
29
Drainage - thin, watery, pink
Serosanguineous | Normal with acute inflammation
30
Drainage - thin, watery, clear
Serous | Normal with acute inflammation
31
Drainage - Thick or thin, opaque, creamy yellow
Purulent Does not always mean infection Pus = cellular debris
32
Drainage - thick, opaque yellow, green, rust
purulent - this one does mean infection | usually will have some odor too
33
Drainage - thick, stringy white or pale yellow
fibrosis fibrotic wound is healing badly disarray in the proliferative phase - impairs granulation
34
Exudate vs. Slough
Exudate - fluid and cells generated by healing process, can be thick or stringy Slough = devitalized necrotic tissue mixing with exudate to make slough (if you dry out slough = eschar)
35
Slough description
Moist devitalized host tissue Can be firmly attached or loose Some say it is liquefying necrosis Recent suggestion of biofilm related slough
36
Slough - Color
Color will vary from creamy, yellow, and tan (depnds on hydration)
37
Slough - Consistency
May be slimy, gelatinous, stringy, clumpy, or fibrous in consistency
38
Slough - contains
Proteinaceous tissue Fibrin Neutrophils Bacteria
39
Wound edge/margin
Moisture level Shape Condition
40
Wound edge/margin - rolled edges
Tight and contracted Epithelialiazation that gets to wound margin and starts to roll over and then stops because hits the bottom and has nowhere else to go Indicates that the wound is maintaining in a chronic proliferative stage
41
Wound edges can also be
Macerated - too much fluid | Drying out - can make them crumbly too
42
Neuropathic ulcer - often have what
Callus around them that have to be debrided away Remarkably dry Right over metatarsal bone
43
Wound bed/base - look at
Color Necrotic tissue Slough or fibrin deposits Anatomic structures visible?
44
Wound bed/base - color
Pale red or pink = arterial issue | Beefy red = good granulation tissue
45
Wound bed/base - Necrotic tissue
Adhered Amount in relationship to size of wound bed Can use percentage for saying how much is covered with necrotic tissue
46
Eschar is typically what on the wound? (convex or concave)
Concave | Tends to be smooth
47
Arterial ulcers tend to have what characteristics
Very dry surrounding area that is lacking hair follicles Very dry in general too Symmetrical wound margins Might see cellulitis going up the leg
48
Culture methods
Biopsy is the gold standard - is invasive though, usually requires local, and is expensive Swab - most common Bone probe
49
Culture swab
1 Clean wound 2 Select cleanest area 3 Using firm pressure, move swab over selected area rotating 360 degrees 4 Avoid wound edges 5 Transport specimen - needs to be done according to protocol
50
Culture methods - when would you bone probe
When suspect osteomyelitis When probe, it breaks apart, can send a piece to culture Best for bone is diagnostic imaging though
51
When would you do a culture?
Is suspect infection | Usually you don't bother - but you would if have chronic wound that won't heal or something else stands out at you
52
Surrounding tissue/Peri wound area - look at
Color Edema Condition
53
Surrounding tissue/Peri wound area - Color
Darkened pigmented - may indicate damaged tissue | Redness - inflammation, cellulitis
54
Surrounding tissue/Peri wound area - Edema
Need to measure it How far does it extend Is it pitting
55
Surrounding tissue/Peri wound area - Condition
Dry, flaky Macerated (wet) Indurated (hard) Lipodermatosclerosis (hard but with specific color, bounces back a little more too)
56
Surrounding tissue/Peri wound area - Symmetry
Cellulitis - usually asymmetrical surrounding | Inflammation - usually more symmetrical surrounding
57
Foot deformities/Pressures
Look for calluses, corns Malformed nails Make note of any deformities - hallux valgus, pes planus, pes cavus, hammer toes

Practice topics Exam 2 (15 decks)

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