Assessment Flashcards
What is the perpendicular method?
Measure wound size. longest length by greatest width @ 90 degrees perpendicular to one another.
How to calculate percent change of wound size.
[(Baseline area-current area)/base line area] x 100 = % change in x amount of time
Less than what wound depth is negligible
.2 cm
Crater
tissue defect extending at least to the subcutaneous layer
Dead space
any open area produced as the result of undermining, tunneling, or sinus tracking
Dermis
Contains blood vessels, nerve endings, epidermal appendages. Composed of collagen, and elastin fibers, thickness depends on site and function
Epidermis
functions for protection, sensation and temperature control.
Stratum corneum - outermost layer slough every 28 days.
Basal cell layer adjacent to dermis and divides constantly. Thickness depends on site and function
Fistula
abnormal passage between two organs or between an organ and the outside of the body
Sinus tract
A soft cavity or channel without defined edges that involves an area larger than the visible surface of the wound.
Tunneling
Deeper open space with defined walls
Undermining
The rim of the wound is eroded beneath the surface.
Black wound classification
Presence of necrotic tissue, exudate usually dry, least healthy. Needs debridement/cleaning
Yellow wound classification
Presence of necrotic tissue, possible infection, exudate usually heavy, less healthy than red wound, needs debridement/cleaning
Red wound classification
Clean, exudate mild to moderate (at times heavy), granulating/healing, healthiest.
How are venous ulcers classified?
CEAP. Pain, edema, claudication, pigmentation, lipodermatosclerosis, ulcer size, duration, recurrence, number
