Lab 1 - Exam & Eval of Wounds Flashcards
The head of a wound (12) is always based on ____________ using the clock method
Anatomical position
Sinus tract
Extends from skin to an abscess or cavity (often expels drainage)
Tunnel
Destruction of fasical planes (usually has destination)
T or F: Use clock terms when describing tunnels and sinuses
T
What is undermining?
Erosion underneath the wound edges/skin
T or F: You can use a sterile measuring device or a sterile cotton swab to measure wound depth
T
Wounds are measured in what measurment system
Metric
Wound depth isnt clear until __________
The wound bed is cleared of debris
T or F: Use a new probe for each wound
True
What is wound tracing?
Using a transparent sheet with graph boxes and a marker to trace the outline of wound
Pros: Fast, easy, inexpensive, reliable
Cons: Difficult to get into electronic chart
All photographic wound measurement tools must be…
HIPAA compliant
all photos include: Patients name, date, wound location, and measuring tool for scale
Total Body Surface Area
For use on wounds so large that other uses of meausrement arent realistic
example: burns
Volumetric measurement
Seeing how much silicone molding or saline fills the wound
Not recommended
Granulation tissue is described as ______
Beefy
This is healthy healing tissue that you want
Friable tissue
Pink
“Crumbly”
Sign of poor circulation (will not heal without intervention)
Slough
Made of WBC, bacteria, degraded ECM
Yellow
T or F: Slough means infection
F
Eschar
Brown leathery
the result of tissue death
Wounds covered in Eschar are usually ______
Full thickness
Full thickness wound
Subcutaneous tissue exposed
(Muscle/bone/tendons/fat)
Partial thickness wound
Through the epidermis
dermis is damaged
superficial wound
only epidermis is damaged
Where does wound odor come from?
Wound drainage
Ideal wound edges:
Flush to wound bed
Moist and open with epithelial rim
Pale/pink to translucent
What is epibole
Raised skin around the wound edge
needs to be scraped/removed to signal skin needs to keep growing
What is hyperkeratosis
Callous forming around wound
What do you need to note about the periwound?
Quality of skin
Color
Hair/nails
Edema
Temp
Circulation
Sensory
What is a maceration of the periwound
From a soaked bandage
skin got too wet with wound drainage
What is skin Turgor
property of skin where when you pinch and pull it off, it takes a moment to become flat again
What is a hemosiderin stain
RBC get through capillaries and stain skin surrounding wound
Can be a sign of venous insufficiency
1+ pitting edema
barely perceptible depression
less than 2mm indent
2+ pitting edema
Easily identifiable, less than 15 second rebound
2-4mm
3+ pitting edema
depression takes 15-30s to rebound
5-7mm
4+ pitting edema
Depression lasts for 30+ seconds
+7 mm
What is the grade of a normal pulse?
2+
