Examination of Wounds Flashcards
What should you do when a patient presents with an open wound?
Check for signs of infection and then check pulses!
Non-audible, do ABI
Audible: Debride if > 50% necrotic or modalities if
What should you be particularly interested in when performing a Wound Assessment?
Diabetes, CHF, PVD, HTN, Kidney failure, incontinence, and previous diagnostic/lab test results
How to measure wounds?
In anatomical position and in centimeters
What is Planimetry?
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
What is a sinus tract?
Course or pathway that can extend in any direction from the wound surface - entrance, no exit.
What is a tunnel?
Sinus tract with an exit
What is undermining?
Wound edge erosion where fascia separates from deeper tissue
How are tunnels, undermining, and sinus tracts measured?
Like a clock
What % of people cannot feel wounds
60-75% per Kathy Leahy
What are some different wound classification systems?
NPUAP Pressure Ulcer Staging System
Wagner Classification System (Diabetes)
CEAP - Venous Disease
Fontaine Staging - Arterial Disease
How is drainage volume classified? What are the different categories?
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!
What is the PUSH tool?
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
What is Exudate?
Wound drainage that contains dead cells and debris
What is Transudate?
Clear fluid drainage
What is pus?
foul smelling and viscous yellow/gray or green exudate (there is an odor, different than purulent)
What are the 4 different drainage consistency categories?
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
What is sanguinous??
thin, bloody, bright red
Serosanguinous?
thin, watery, pale red to pink
Serous?
thin, watery, clear
Purulent?
Creamy or thick, opaque to yellow (like pus but NO ODOR)
What are the different wound edges?
Clean Surgical Rolled Thickened Detatched Fibrotic (thick and hard) - common in first met head
What are the different wound shapes?
Linear Irregular Punched Out Flap Round
What are the different wound assessment classifications for the periwound?
Intact Scarring Hemosiderin stained Ecchymotic Inflammed Erythema Adhesive Reaction (bandaid on skin) Excoriated Macerated Edematous - swollen, full of fluid Indurated Fluctuant Skin temperature
What does hemosiderin stained mean?
chronic insufficiency levels, blood cells break up and stain the skin
What does ecchymotic mean?
Bruised
What is the difference between erythema and inflamed?
I = response to inflammation process (usually associated with infection)
E = part of normal wound healing
What is excoriated?
Bright red like a diaper rash - looks like it hurts
What is macerated?
White, pruny, and wet (“wet bandaid finger”) - but not adhesive reaction
What is indurated?
Full of fluid and hard
What is fluctuant?
Loose fluid, like tapping a water balloon
What are indications if the wound is hot or cold?
Hot = warmth of inflammation
Cold - arterial disease in feet
How to measure edema?
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
How to document wound pain?
Prescence or absense
Level: 0-10, faces, non-verbal, dementia scale
Changes in symptom: worse/better
Questions to ask about pain?
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
What are the 5 levels of infection?
Sterile Contaminated Colonized Critically colonized Infected
What is contamination?
Presence of replicating organism in the wound
What is colonization?
Presence of replicating organism in wound WITHOUT host immune response
What is infection?
Presence of replicating organism in wound WITH host immune response
What characterized local infection?
Erythema, pain, odd color, drainage, odor, warmth
What characterizes systemic infection?
WBC, temp, increased glucose, lethargy or mental status changes, decreased systolic BP
What are different types of cultures for infection assessment?
Swab Aspiration Punch biopsy Tissue sample Bone sample
What is the Z-Technique?
10 points across wound in a Z-pattern
What is the Levine Technique?
1 sq cm is tested
-Express exudate from wound
Is diagnosing infection a clinical skill or microbiologic technique?
Clinical skill
What does culturing tell you?
What antibiotic to use! (not whether you have an infection or not)
What is the difference between periwound erythema, dependent rubor, and infection
Periwound erythema - normal reaction to initial wounding
Dependent rubor - vascular condition
Infection - infection
