Lab 1 - Exam & Eval of Wounds

Question 1

The head of a wound (12) is always based on ____________ using the clock method

Answer 1

Anatomical position

Question 2

Sinus tract

Answer 2

Extends from skin to an abscess or cavity (often expels drainage)

Question 3

Tunnel

Answer 3

Destruction of fasical planes (usually has destination)

Question 4

T or F: Use clock terms when describing tunnels and sinuses

Answer 4

T

Question 5

What is undermining?

Answer 5

Erosion underneath the wound edges/skin

Question 6

T or F: You can use a sterile measuring device or a sterile cotton swab to measure wound depth

Answer 6

T

Question 7

Wounds are measured in what measurment system

Answer 7

Metric

Question 8

Wound depth isnt clear until __________

Answer 8

The wound bed is cleared of debris

Question 9

T or F: Use a new probe for each wound

Answer 9

True

Question 10

What is wound tracing?

Answer 10

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

Question 11

All photographic wound measurement tools must be…

Answer 11

HIPAA compliant

all photos include: Patients name, date, wound location, and measuring tool for scale

Question 11

Total Body Surface Area

Answer 11

For use on wounds so large that other uses of meausrement arent realistic

example: burns

Question 11

Volumetric measurement

Answer 11

Seeing how much silicone molding or saline fills the wound

Not recommended

Question 11

Granulation tissue is described as ______

Answer 11

Beefy

This is healthy healing tissue that you want

Question 12

Friable tissue

Answer 12

Pink

“Crumbly”

Sign of poor circulation (will not heal without intervention)

Question 13

Slough

Answer 13

Made of WBC, bacteria, degraded ECM

Yellow

Question 14

T or F: Slough means infection

Answer 14

F

Question 15

Eschar

Answer 15

Brown leathery

the result of tissue death

Question 16

Wounds covered in Eschar are usually ______

Answer 16

Full thickness

Question 17

Full thickness wound

Answer 17

Subcutaneous tissue exposed

(Muscle/bone/tendons/fat)

Question 18

Partial thickness wound

Answer 18

Through the epidermis

dermis is damaged

Question 19

superficial wound

Answer 19

only epidermis is damaged

Question 20

Where does wound odor come from?

Answer 20

Wound drainage

Question 21

Ideal wound edges:

Answer 21

Flush to wound bed

Moist and open with epithelial rim

Pale/pink to translucent

Question 22

What is epibole

Answer 22

Raised skin around the wound edge

needs to be scraped/removed to signal skin needs to keep growing

Question 23

What is hyperkeratosis

Answer 23

Callous forming around wound

Question 24

What do you need to note about the periwound?

Answer 24

Quality of skin

Color

Hair/nails

Edema

Temp

Circulation

Sensory

Question 25

What is a maceration of the periwound

Answer 25

From a soaked bandage

skin got too wet with wound drainage

Question 26

What is skin Turgor

Answer 26

property of skin where when you pinch and pull it off, it takes a moment to become flat again

Question 27

What is a hemosiderin stain

Answer 27

RBC get through capillaries and stain skin surrounding wound

Can be a sign of venous insufficiency

Question 28

1+ pitting edema

Answer 28

barely perceptible depression

less than 2mm indent

Question 29

2+ pitting edema

Answer 29

Easily identifiable, less than 15 second rebound

2-4mm

Question 30

3+ pitting edema

Answer 30

depression takes 15-30s to rebound

5-7mm

Question 31

4+ pitting edema

Answer 31

Depression lasts for 30+ seconds

+7 mm

Question 32

What is the grade of a normal pulse?

Answer 32

2+