Integ PT Exam Wound Exam - Class 3 Flashcards
pt protection
prevention of nosocomial infections
antimicrobial prophylaxis prior to surgery
hand washing
antimicrobial prophylaxis prior to surgery
reducing intestinal flora before surgery
preventing bacteria access to the wound
cleaning the wound by mechanical methods
administering antibiotics prophylactically
controlling wound infection –> pt
boost immune response
glucose control
IV antibiotics
nutrition
hydration
hyperbaric therapy
controlling wound infection –> wound
debride necrotic tissues
remove infected foreign objects
absorb heavy exudates
irrigation and debridement
controlling wound infection –> dressings
non-occlusive
absorptive
topical antimicrobials
silver based
honey based
pt eval
history
current health status
nutrition and hydration status
mental health
fxnal status
strength and ROM
pt eval –> subjective exam
pains behavior
pain rating scales
pains behavior
positional
time
nature
wound exam –> objective
location (by anatomical position)
size
depth
depth of wound
size of the wound
linear measurement LxW in cm
greatest length - greatest width
clock method
depth
tunneling or undermining
full/partial thickness
pressure staging system
tunneling
has a definitive end
angular
undermining
no end
goes into something else
depth of wound
classification with staging system
classification by thickness
classification with staging system
for pressure ulcers only
classification by thickness
partial
full
stages of classification by staging system
suspected deep tissue injury
stage 1-4
unstageable
suspected deep tissue injury
purple or maroon localized area of discolored intact skin
blood filled blister d/t damage of underlying soft tissue from pressure and/or shear
area may be preceded by –> suspected deep tissue injury
tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue
stage 1 –> appearance
non-blanchable erythema of intact skin
usually over a bony prominence
stage 1 –> darker skin
non-blanchable redness may not be visible
presents with discoloration, warmth or coolness, edema, induration and pain
stage 1 –> ________ of skin ulceration
heralding lesion
stage 2
partial thickness skin loss
involving epidermis and or dermis
does not fully go through dermis
stage 2 –> clinically presents
blister (intact or open/ruptured serum filled), abrasion, shallow crater
stage 2 –> wound bed
red/pink
moist
stage 2 –> differentiated from
skin tears
tape burns
dermatitis
maceration or excoriations
stage 3
full thickness skill loss
involving damage to subcutaneous tissue
may extend to fascia but NOT THROUGH IT
stage 3 may have
undermining or tunneling
stage 4
full thickness skin loss w/ extensive tissue destruction
stage 4 damage
extends to muscle, bone, tendons and joint capsule
unstageable
full thickness tissue loss in which the base of the ulcer is covered by slough +/or eschar in the wound bed
slough
yellow
tan
grey
green
brown
eschar
tan
brown
black
wound edges
distinct v. indistinct
attached v. unattached
are the wound edges
hyperkeratotic
ischemic
macerated
tissue type
is it bone, tendon, fascia, muscle, fatty tissue
exposed grafts or vessels
necrotic and granulation tissue
necrotic tissue
choose most predominant type
quantify in percentages
granulation tissue
beefy red
pink or dusky
hyper granulating
epithelialization
& of wound margin
exudate
type and amount
type of exudate
serous
sanguineous
serosanguinous
purulent
foul purulent
amount of exudate
none
scant
minimal
moderate
heavy
wound infection
red granulation tissue that has ceased for a period of time
to progress towards contraction and epithelialization
hyper granulation tissue
wound culturing
needle aspirations/biopsies
swab culturing
peri wound tissue
assess color
temp
moisture
tissue edema
asses within 4.0 cm of wound edge
pitting v. non-pitting
presence of induration
edema assessment
part of the wound examination
