Lab 1&2: wound assessment Flashcards
1
Q
Arteral wound
location:
tissue:
Pain:
skin:
exudate:
A
- location: Distal digits (toes or fingers)
- tissue: Dry, necrotic or slough little or no granulation
- Pain: yes, may have dependent leg syndrome or rest pain
- skin: dry, hairless, shiny, thin, postive rubor of dependcy
- exudate: none unless infected due to blood not getting to tissue
2
Q
Venous wound
location:
tissue:
Pain:
skin:
exudate:
A
- location: lower 1/3 of leg (called gaiter area)
- tissue: red or pink, bark texture, yellow slough poor granulation
- Pain: generally no painful unless vasculitic or infected
- skin: hemosiderous staining, atrophie blanche
- exudate: varies may have copious serous drainage
3
Q
Pressure wounds
location:
tissue:
Pain:
skin:
exudate:
A
- location: over bony prominences
- tissue: varies from non-blanchable erythema to dark red to eschar (dying tissue)
- Pain: varies depending on the structures involved
- skin: discolored from erythematous to hypoxic may be macerated or excoriated
- exudate: varies, depending on infection
4
Q
Neuropathic wounds
location:
tissue:
Pain:
skin:
exudate:
A
- location: weight-bearing surface of the foot or dorsal digits (also arterial dysfunction)
- tissue: callus or blister, slough, may probe to bone, nectroic with PAD
- Pain: none until infected then deep throbbing (didnt feel injury)
- skin: dry, thickness, scaly, hyperkeratotic
- exudate: varies depending on infeciton
5
Q
Subjective interview for wounds
A
- when and how did the wound begin
- precipitating events
- previous treatments
- other signs and symptoms
- describe the pain/quantity and quality/alleviating or precipitating factors
- comorbidities
- meds and allergies
- nutritional status
- alcohol, drug, tobacco use
- physical activity level
- assistive devices/shoes
- patient goals
6
Q
Melanoma
A
- a tumor of the melanocytes of the epidermis
- common cause is exposure to UV sunlight or tanning beds
- early melanomas are highly treatable
- our role is in referral if we note any abnormal skin lesion
- first line of treatment is excision of the tissue involved
- ABCDE
7
Q
Skin assessment: what to think about
A
- good lighting
- patient position
- modesty and comfort
- adequate exposure of the wound and surrounding tissue
- observe initial appearance and then after cleaning
8
Q
Describe wound location
A
- aids in determining wound etiology
- described by anatomical body part using medical terminology
- BE SPECIFIC
- want to be able to say where
- could measure from bony landmark
9
Q
2 methods to measure surface area: length x width use metric
A
- clock method
- perpendicular method
10
Q
Depth
A
- used for volume measurement
- if slough or necrotic tissue covers the wound, state “unable to determine”
- if depth is minimal state as 0.1
11
Q
Wound tracing
A
- before placeing the tracing guide on the wound, a clear plastic film is placed on the wound to prevent fluids from getting on the tracing
- the tracing guide is placed over the first layer of plastic filme and wound is traced ith an indelible marking pen
- recommended for serpentine wounds that do not have well-defined lenghts and widths
12
Q
Undermining
A
- disrupted attachment of the skin to the tissue below
- probe horizontally underneath edges
this will not heal
13
Q
tunneling/sinus tract
A
- wound extensions that usually run through tissue or along fascial places
- sinuses are not considered deepest depth for volume measurement
- sinuses: extensions that run along fascial plane and may contain fluid trapped in the deeper area
- tunneling occurs when two cutaneous wounds connect
14
Q
tissue types
eschar/nectrotic
A
- may be black, brown, yellow, tan
- bad/not viable tissue
- if its on a heal usually left there
15
Q
tissue types
slough
A
- usually soft, yellow and adherent
- need to take off to look for wound healing
