Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Integ - PTH 703 - Unit 1 > Examination of Wounds > Flashcards

Examination of Wounds Flashcards

1
Q

What should you do when a patient presents with an open wound?

A

Check for signs of infection and then check pulses!

Non-audible, do ABI
Audible: Debride if > 50% necrotic or modalities if

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What should you be particularly interested in when performing a Wound Assessment?

A

Diabetes, CHF, PVD, HTN, Kidney failure, incontinence, and previous diagnostic/lab test results

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How to measure wounds?

A

In anatomical position and in centimeters

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is Planimetry?

A

Use of a mechanical or digital tool that measures L x W only

L - longest length cephalad to caudad (12-6)
W - widest width from left to right (9-3)
D - deepest part of the base to the skin surface

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is a sinus tract?

A

Course or pathway that can extend in any direction from the wound surface - entrance, no exit.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is a tunnel?

A

Sinus tract with an exit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is undermining?

A

Wound edge erosion where fascia separates from deeper tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How are tunnels, undermining, and sinus tracts measured?

A

Like a clock

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What % of people cannot feel wounds

A

60-75% per Kathy Leahy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are some different wound classification systems?

A

NPUAP Pressure Ulcer Staging System
Wagner Classification System (Diabetes)
CEAP - Venous Disease
Fontaine Staging - Arterial Disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How is drainage volume classified? What are the different categories?

A 
None - 0% of drainage on dressing
Scant/small - 1-25% of dressing has drainage on it, compared to the size of the wound
Minimal - 25-50%
Moderate - 51-75%
Large - 76-100%
Copious - SOAKED!
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the PUSH tool?

A

Estimated amount of exudate using quadrants of wound base for reference

Less than 1/4 = scant/small
1/4 to 1/2 = minimal
1/2 to 3/4 = moderate
Greater than 3/4 = large

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is Exudate?

A

Wound drainage that contains dead cells and debris

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is Transudate?

A

Clear fluid drainage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is pus?

A

foul smelling and viscous yellow/gray or green exudate (there is an odor, different than purulent)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the 4 different drainage consistency categories?

A

Watery - usually clear or transparent (broth)
Creamy - can’t see through, but still very liquid-like (watery tomato soup)
Thick - can’t see through, more like thick pea soup
Pus - thick and has odor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is sanguinous??

A

thin, bloody, bright red

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Serosanguinous?

A

thin, watery, pale red to pink

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Serous?

A

thin, watery, clear

20
Q

Purulent?

A

Creamy or thick, opaque to yellow (like pus but NO ODOR)

21
Q

What are the different wound edges?

A 
Clean
Surgical
Rolled
Thickened
Detatched
Fibrotic (thick and hard) - common in first met head
22
Q

What are the different wound shapes?

A 
Linear
Irregular
Punched Out
Flap 
Round
23
Q

What are the different wound assessment classifications for the periwound?

A 
Intact
Scarring
Hemosiderin stained
Ecchymotic
Inflammed
Erythema
Adhesive Reaction (bandaid on skin)
Excoriated
Macerated
Edematous - swollen, full of fluid
Indurated
Fluctuant
Skin temperature
24
Q

What does hemosiderin stained mean?

A

chronic insufficiency levels, blood cells break up and stain the skin

25
Q

What does ecchymotic mean?

A

Bruised

26
Q

What is the difference between erythema and inflamed?

A

I = response to inflammation process (usually associated with infection)

E = part of normal wound healing

27
Q

What is excoriated?

A

Bright red like a diaper rash - looks like it hurts

28
Q

What is macerated?

A

White, pruny, and wet (“wet bandaid finger”) - but not adhesive reaction

29
Q

What is indurated?

A

Full of fluid and hard

30
Q

What is fluctuant?

A

Loose fluid, like tapping a water balloon

31
Q

What are indications if the wound is hot or cold?

A

Hot = warmth of inflammation

Cold - arterial disease in feet

32
Q

How to measure edema?

A 
Always measure in cm
Use bony landmarks! Common ones:
-Met heads
-Midfoot
-Figure 8
-10 cm up from medial malleoli
-20 cm up from medial malleoli
33
Q

How to document wound pain?

A

Prescence or absense
Level: 0-10, faces, non-verbal, dementia scale
Changes in symptom: worse/better

34
Q

Questions to ask about pain?

A

Elevation or dependent better?
Dressing removal: does it stick?
If wound has been debrided, did the debridement hurt? If no, were you medicated at the time?

Think about:

  • Eliminating cause
  • Protecting wound margins
  • Carefully select debriding options
  • Control inflammation and edema
  • Stabilize the wound for mobility
  • Address ache and anguish
35
Q

What are the 5 levels of infection?

A 
Sterile
Contaminated
Colonized
Critically colonized
Infected
36
Q

What is contamination?

A

Presence of replicating organism in the wound

37
Q

What is colonization?

A

Presence of replicating organism in wound WITHOUT host immune response

38
Q

What is infection?

A

Presence of replicating organism in wound WITH host immune response

39
Q

What characterized local infection?

A

Erythema, pain, odd color, drainage, odor, warmth

40
Q

What characterizes systemic infection?

A

WBC, temp, increased glucose, lethargy or mental status changes, decreased systolic BP

41
Q

What are different types of cultures for infection assessment?

A 
Swab
Aspiration
Punch biopsy
Tissue sample
Bone sample
42
Q

What is the Z-Technique?

A

10 points across wound in a Z-pattern

43
Q

What is the Levine Technique?

A

1 sq cm is tested

-Express exudate from wound

44
Q

Is diagnosing infection a clinical skill or microbiologic technique?

A

Clinical skill

45
Q

What does culturing tell you?

A

What antibiotic to use! (not whether you have an infection or not)

46
Q

What is the difference between periwound erythema, dependent rubor, and infection

A

Periwound erythema - normal reaction to initial wounding

Dependent rubor - vascular condition

Infection - infection

Integ - PTH 703 - Unit 1 (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions