1.20 Other Wound Types 2 Flashcards
1
Q
When evaluating a wound, check these:
A
- color
- discharge/moisture
- odor
- measurements (depth, length, width)
- tunneling/undermining
- eschar
- slough
- texture
2
Q
evaluating a wound: color
A
- periwound
- wound bed
3
Q
evaluating a wound: how to orient
A
typically like a clock (12 to the head, 6 to the feet)
4
Q
evaluating a wound: varying depth?
A
measure at shallowest and deepest
5
Q
evaluating a wound: undermining
A
- think about how much based on collapse of more superficial tissue
- upper layer may stay healthy
6
Q
undermining occurs most with
A
decubitus ulcers
7
Q
evaluating a wound: tunneling
A
- tunnels deeper, typically at the bottom of a wound bed
- packed with thin strips of gauze
8
Q
fistula
A
when a tunnel communicates with another part of the body
9
Q
impact of fecal matter and urine in a wound
A
- acts as a chemical burn and eats through tissue
- infection
10
Q
eschar
A
black, leathery, dry, necrotic tissue
11
Q
slough
A
stringy, mucousy, loogie-like
12
Q
evaluating a wound: texture
A
- granulation tissue: (bumpy and red)
- crusty/dry (beef jerky)
13
Q
Why would surgical debridement be necessary?
A
- usually have a lot of dry eschar
- hasn’t been taken care of properly
- need to start from square one and cut down to healthy tissue
