Integ. Unit 3 Wound Assessment/Evaluation Flashcards
(Step 1 of Wound Assessment)
What takes place in the General Assessment?
- Hx Taking (gathering data, review admission/referral, Pt Hx)
- Wound Associated Factors (wound onset, etiology, S/S, Pain, Psychosocial hx)
(Step 2 of Wound Assessment)
What are the 2 parts of the Diagnosis Portion?
Part A: Examination strategy
- This is more focused than General assessment
- Has 2 sub-parts:
–sub-part 1: Testing for factors related to co-morbidities
–sub-part 2: Wound examination
Part B: Evaluation/Diagnosis
- Analyses of all findings
- Formulation clinical decision making
- Guides intervention strategies
- Involves disabilities and functional diagnosis
What takes place during the Observation portion of the assessment?
- Patient positioning
- using cleaning technique, remove any dressing and clease the wound
- Observe the wound
- Observe periwound (tissue surrounding wound)
What are different Methods to obtain Wound Dimensions?
Perpendicular
- Length: Longest Dimension
- Width: Longest dimension perpendicular to length
(good reliability)
Clock Method
- Utilizes clock face to describe the dimensions of a wound
- 12 o’clock is always cephalically
- Must document pt position
Tracing/wound photography
- Plastic measuring guide placed over wound
- Digitial photos with planimetry
With the Clock Method, how is the wound measured?
- Length x Width x Depth in cm
-Length: measurement from “head to toe” direction (from 12 o’clock to 6 o’clock)
-Width: perpendicular to length. Usually measured at its max width from 9 o’clock (ish) to 3 o’clock (ish)
-Depth: Using a cotten tipped applicator, bottom of wound is probed until max depth is recorded
What are the 2 Subcutaneuous Extensions with Wound Management?
Undermining
- May or may not be characterized by a discolored skin around the periphery of the wound
- Documentation includes depth and migration using clock technique
Tunneling
- Can be between 2 wounds
- Can be within the same wound at an angle
With Tissue Types, what is Eschar?
- Non-Viable/Nectrotic tissue
- Usually a black/brown appearance
- Varies in texture (hard, dry)
With Tissue types, what is Slough?
- Non-viable subcutaneous tissue
- Result of autolytic debridement
- Soft yellow tissue
With Tissue types, what is Granulated tissue?
- Viable tissue
- Usually noted to be a “beefy red” appearance
- Composed of ECM and capillaries
Are muscle and bone Viable or Non-Viable tissue?
Both can be non-viable tissue
- Based on nuritional characteristic
What tissue type are Tendons?
Are they Viable or Non-viable?
These can be non-viable
- They can be visualized with full thickness wounds
- Viable tendon must remain moist to prevent desiccation or dryness as this would decrease the viability of the tissue
(Still characterized as viable if it still contains is surrounding peritenon sheath, if it looks shiny)
What tissue type are Adipose Tissue?
Are they viable or non-viable?
This can be non-viable
- Characterized by shiny globules when viable and has a dull yellow appearance when non-viable due to delayed vascularization
- Adipose tissue is slow to vascularize which may cause it to be non-viable
What is Hypergranulation tissue?
- This is characterized as granulation tissue that overrides the tissue surface and is a sign of abnormal healing
- Although red which is generally referred to as healthy tissue will cause an inability to heal as the edges will not be able to approximate up over the edges of the granulation tissue
In reference to the amount of drainage, what does scant mean?
Small remnant of drainage on dressing after removal
In reference to the amount of drainage, what does minimal drainage mean?
~ 25% of the dressing is covered
In reference to the amount of drainage, what does Moderate drainage mean?
~ 50% of the dressing is covered
In reference to the amount of drainage, what does Heavy drainage mean?
~ 100% of the dressing is covered
In reference to the amount of drainage, what does Copious mean?
Multiple layers of dressing are covered
In reference to the amount of drainage, what does Strike Through mean?
Drainage visable through the last layer of dressing (unable to be contained by the dressing)
In reference to the Type of Drainage, what is Serous?
Clear serum
- Normally occurs in the inflammatory stage of healing
In reference to the Type of Drainage, what is Sanguineous?
“Bloody”
In reference to the Type of Drainage, what is Serosanguineous?
A mixture of serous and sanguinous
(Clear and bloody)
- Usually more pinkish
In reference to the Type of Drainage, what is Purulent?
Thick, and viscous, may be smelly; “pus”
In reference to the Type of Drainage, what is Infected?
Usually mal odorous
- Can often be various colors
What is Peri-wound and its characteristics?
Periwound is the skin surrounding the wound
Characteristics:
- Erythema: redness
- Ischemic: Pale
- Hemosiderin Staining: Brown/purple discoloration typcial with venous insufficiency (More in the distal aspects of the lower legs)
- Eccymosis: bruising
- Maceration (too much water)
When removing the dressing of a wound sometimes the wound will have an odor. What type of odor is Pseudomonas?
This is characterized as sweet odor
- “Corn Tortilla”
This is also a type of bacteria that has a green appearance
When removing the dressing of a wound sometimes the wound will have an odor. What type of odor is Wet Gangrene?
This is characteristically a foul odor
After a diagnosis is obtained, we establish a prognosis. What takes place in the prognosis?
- Predicted expected outcomes
- Estimation of therapy frequency/duration
Common prognosis:
-Wound closure
-Clean and stable wound
-Wound not expected to improve
After the prognosis, goals are made (using SMART)
