Integumentary: Examination of Wounds Flashcards
1
Q
Examination: Location
A
- Examine for location of wound using anatomical landmarks
2
Q
Examination: Assess Size
A
- Clear film grid superimposed on wound for size
- Insert sterile cotton tip into deepest part of wound for depth
- Indicate gradations of depth from shallow to deep
- Length
- Width
- Area
3
Q
Examination: Tunneling
A
- Tissue destruction beneath intact skin
- Sinus tracts (communication with deeper structures)
4
Q
Examination: Exudate: Serous
A
- Watery serum
5
Q
Examination: Purulent
A
- Containing Pus
6
Q
Examination: Sanguineous
A
- Containing Blood
7
Q
Examination: Maceration
A
- Softened tissues due to high fluid environment
8
Q
Examination: Color: Red
A
- Granulation wounds
- No necrotic tissue
- In need of protection
- Healthy tissue
9
Q
Examination: Color: Yellow
A
- Include slough (necrotic or dead tissue)
- Fibrous Tissue
10
Q
Examination: Color: Black
A
- Covered in eschar
11
Q
Examination: Indolent Ulcer
A
- Slow to heal
- Not painful
