Examination Of Wounds Flashcards
Assess size:
- How to assess length/width?
- How to assess depth?
- Clear film grid superimposed on wound
- Insert sterile cotton tip applicator into deepest part for wound depth; indicate gradations of depth from shallow to deep
Examine for ____ (underlying tissue destruction beneath intact skin)
Tunneling (rimming/undermining)
Evaluate for ____ (communication with deeper structures); associated with unusual or irregular ____.
Sinus tracts
Borders
Determine wound exudate or drainage:
- Watery aka?
- Containing pus aka?
- Containing blood aka?
- Serous
- Purulent
- Sanguineous
Determine wound exudate or drainage:
4 things to assess
- Type
- Amount
- Odor
- Consistency
ID color and tissues involved:
What does clean red wound indicate?
Healthy granulating wounds; absence of necrotic tissue
ID color and tissues involved:
What does yellow indicate?
Slough (necrotic or dead tissue), fibrous tissue
ID color and tissues involved:
What does black indicate?
Covered with eschar (dried necrotic tissue)
ID color and tissues involved:
What is an indolent ulcer?
Slow to heal; not painful
ID color and tissues involved:
Check to see if ___ involved
Fascia, muscle, tendons, bone
ID color and tissues involved:
Record what?
If epithelization or granulation present
Determine temperature: indicative of ?
Inflammation
Determine girth: use ____ of ___ and reference bony landmarks
Circumferential measurements
Involved and uninvolved limbs
Determine girth: use ____ measurements with water displacement
Volumetric
Examine viability of periwound tissue:
What is a halo of erythema indicative of?
Warmth, swelling, infection (cellulitis)
