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)
Examine viability of periwound tissue:
___ of surrounding tissues due to moisture (urine, feces) or wound ___ increases risk for wound __ and ___
Maceration
Drainage
Deterioration, enlargement
Examine viability of periwound tissue:
Trophic changes may indicate what?
Poor arterial nutrition
Examine viability of periwound tissue:
Cyanosis may indicate what?
Arterial insufficiency
Determine ___ integrity, risk for trauma or pressure breakdown
Sensory
Examine for signs of infection through ___, ___, and ___
Bacterial culture, observation, palpation
How would you use photographic records?
Record of wound appearance aids narrative description. Use marker pen to outline wound edges on transparent dressing with calibrated grid to provide measuring scale.
Imaging for wound care:
Arterial system?
Venous system?
Arterial: Arteriorgram, Doppler US, MRAngiography, CT angiography
Venous: Doppler US, MRVenography, CT Venography
