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Integumentary > 2] Wound Assessment > Flashcards

2] Wound Assessment Flashcards

1
Q

Why is assessment and documentation important?

A

For communication
Denied payment for stage 3 and 4 pressure injuries not documented on admission in some settings
Side with most data wins
If you didnt write it, you didnt do it

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2
Q

Diagnoses that are risk factors

A 
Diabetes
Plegias 
Urinary incontinence or chronic bowel 
Sepsis 
Terminal illness
C-diff
Immobile
Hip surgery
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3
Q

Measure wounds in ?

A

Cm

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4
Q

What is undermining

A

Open skin at the surface caused by shearing

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5
Q

Documentation of measure of a wound tunneling and undermining

A

Undermining from 3:00 - 7:00 with depth of 1.5 cm at 7:00

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6
Q

passageway belowsurface of skin in
any direction from
surface or edge of
wound

A

Tunneling

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7
Q

thick, leathery, necrotic, devitalized

tissue

A

Eschar

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8
Q

Slough is ?

A

Necrotic tissue

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9
Q

Epithelialization is in the ?

A

Epidermis

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10
Q

cells
migrating across
wound surface;
color could range from glass to pink

A

Epithelialization

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11
Q

buildup of tissue that
inhibits
epithelialization (when granulation tissue
exceeds skin height)

A

Hypergranulation

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12
Q

Assess wound drainage amount

A

Minimal
Light
Moderate heavy

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13
Q

4 types of wound drainage

A

Serous
Serosangineous
Sangineous
Purulent

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14
Q

clear or light-yellow plasma

A

Serous type of drainage

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15
Q

Pink to light red plasma wound drain

A

Serosangineous

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16
Q

Red with fresh blood wound drain

A

Sangineous

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17
Q

Thick drainage, creamy yellow, green, white or tan = infection

A

Purulent type of drainage

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18
Q

What is a maceration type of wound?

A

Too much moisture; over hydrated wound edges

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19
Q

What’s it called when the edge of the wound is rolled under

A

Epibole

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20
Q

Best way to determine infection is with a ?

A

Wound culture

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21
Q

One symptom of wound infection is delayed healing

A

Greater than 4 weeks

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22
Q

What scale is used to assess pain

A

VAS or face scale

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23
Q

What is the Braden scale

A

Predicts pressure sore risk

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24
Q

Highest and lowest possible score for Braden scale

A

23 and 6

25
Q

Less than 9 for Braden scale is

A

Very high

26
Q

PUSH stands for

A

Pressure ulcer scale for healing

27
Q

PUSH does what?

A

Monitors healing over time

28
Q

Normal WBC

A

4500 to 11,000 mm3

29
Q

Low WBC

A

Leuokopenia

30
Q

High WBC

A

Leukocytosis

31
Q

Normal RBC for men

A

4.7 to 6.1 million /ml

32
Q

Normal hematocrit for men

A

42-52%

33
Q

Normal hemoglobin for men

A

14 - 18 g/dL

34
Q

Normal RBC for women

A

4.2 - 5.4 million/mL

35
Q

Normal hematocrit for women

A

37 - 47%

36
Q

Normal hemoglobin for women

A

12 - 16 g/dL

37
Q

Normal RBC lab value

A

150,000 to 400,000 / mL

38
Q

Elevated RBCs

A

Thrombocytosis

39
Q

Deficiency of RBCs

A

Thrombocytopenia

40
Q

What is prothrombin time?

A

Time it takes plasma to clot after addition of tissue factor

41
Q

Normal prothrombin time

A

12 - 15 seconds

42
Q

Prothrombin time is how many times higher for patients with hypercoagulability?

A

1.5 to 2.5 times higher

43
Q

If PT is more than 2.5x normal what happens?

A

Spontaneous risk for bleeding

44
Q

What’s normal PTT?

A

25 - 40 seconds

45
Q

Normal INR

A

0.9 to 1.1

46
Q

Measures intrinsic and common coagulation

pathways

A

PTT

47
Q

Na+ electrolytes that influences swelling

A

135 - 145 mEq/L

48
Q

K+ electrolytes

A

3.5 - 5

49
Q

Hyper or hypokalemia can cause?

A

Arrhythmias

50
Q

Cl-

A

98 - 109

51
Q

HCO3 electrolyte

A

20-30

52
Q

BUn is an indicator of?

A

Renal function and fluid status

53
Q

Normal BUN

A

8 - 25 mg/dL

54
Q

Elevated levels of urea associated with

A

Delayed wound healing

55
Q

Normal creatinine

A

0.6 - 1.4 mg/dL

56
Q

If BUN increases while creatinine decreases, indicates ?

A

Dehydration

57
Q

Normal Hgb A1C

A

Less than 6.1%

58
Q

Glucose when fasting

A

Less than 110 mg/dL

Integumentary (15 decks)

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