Module 2: Wound Assessment Flashcards

1
Q

What is the first thing you must know for a proper WOUND assessment? Why?

A

The ETIOLOGY of the WOUND, understanding the WOUND will help you to make an effective care plan

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2
Q

Where can surgical dehiscence and trauma (skin tears) occur?

A

Anywhere on the body

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3
Q

WOUND location _________ to WOUND ETIOLOGY

A

corresponds

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4
Q

Where are PRESSURE ULCERS normally found?

A

PRESS ULs are typically found over bony prominences, but they can occur
anywhere where there is sustained pressure on the skin that is not relieved

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5
Q

What types of ULs are common in the lower legs?

A

ARTERIAL and VENOUS

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6
Q

Why do ART ULs occur?

A

Poor blood flow, restricted amount of oxygenated blood results in harm to tissues, in this case, ULs

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7
Q

Why do VEN ULs occur?

A

Difficulty flowing back up the heart for proper circulation (pooling of blood in legs).

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8
Q

Why does EDEMA occur with VEN ULs?

A

Because valves in the VEINS are not working properly for circulation and the fluid builds up = EDEMA

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9
Q

“Mixed VENOUS ARTERIAL” indicates:

A

A combination of VEN and ART ULs

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10
Q

What causes NEUROPATHIC/DIABETIC ULs?

A

peripheral neuropathy, structural foot changes, trauma or pressure. When a person is unable to feel their limbs, they are much more susceptible to trauma injury as well.

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11
Q

Where are NEUROPATHIC/DIABETIC ULs normally found?

A

PLANTAR surface of the foot

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12
Q

What characteristic of a WOUND should you be assessing weekly?
(know at least 4)

A
  • pain
  • size,
  • wound bed
  • exudate
  • edge
  • odour
  • Peri-wound skin
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13
Q

What are 3 benefits of involving pts in the WOUND care?

A
  • Allows some Control
  • Reduces Anxiety
  • Adheres to Careplan
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14
Q

How can uncontrolled pain affect infct and healing?

A

Increases the risk of infct and delays healing

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15
Q

Why is WOUND measurement important?

A

This allows you to monitor progress objectively (good vs bad)

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16
Q

Define UNDERMINING

A
  • Destruction of tissue underneath intact skin of the wound edge
    “Behold…THE UNDERMINER!! I am beneath you, but nothing is beneath me! I hereby declare war on peace and happiness! Soon, all will tremble before me!”
  • classic line from The Incredibles hehe i couldn’t help it ;P
17
Q

Define SINUS TRACT

A

A channel that extends in any part of wound base and tracts into deeper tissue.

18
Q

If a WOUND were described as at “12 o’clock” what would this indicate?

A

That this is a head WOUND. 12 o’clock = head of the patient, 6 o’clock = feet.

19
Q

What is the expected healing rate of a WOUND (in %)

A

20-40% in 2-4 weeks.

20
Q

Characteristics of ESCHAR:

A
  • Dry
  • Dead Tissue
  • Black or brown
21
Q

Characteristics of SLOUGH:

A
  • Dry or wet
  • Loose or firmly attached yellow or brown dead tissue
  • Moisture added to wound facilitates this process.
22
Q

T or F:

GRANULATION TISSUE is undesirable during the healing process

A

F, it is desirable, this is new tissue

23
Q

What does GRANULATION TISSUE look like?

A

Firm red and moist pebbled healthy tissue

24
Q

Is superficial pink, red tissue also desirable for healing?

A

Yes

25
Q

What is HYPERGRANULATION TISSUE? is it desirable for healing?

A

It is raised above the level of the skin, not desirable for healing

26
Q

What does NON-GRANULATION TISSUE look like?

A

Moist red, pale to bright: smooth look

27
Q

What is indicated by describing a WOUND BED as FRIABLE?

A

This is unhealthy fragile skin that bleeds easily

28
Q

Factors that impede healing:

know at least 3

A
  • Local or systemic infection
  • Poor nutrition
  • Poor circulation
  • Pressure that is not off-loaded
  • Malignancy
  • Excess or inadequate amount of moisture
29
Q

During a WOUND ASSESSMENT, what underlying structures are important to take note of?

A
  • Bone
  • Tendon
  • Muscle
  • Ligament
  • Fascia
30
Q

What are 3 examples of foreign objects that can delay healing?

A
  • Hardware
  • Sutures
  • Mesh
31
Q

Define BLISTER

A

A separation/elevation of the epidermis containing fluid. Surface intact

32
Q

What is PERIWOUND SKIN?

A

Skin surround WOUND

33
Q

Is an intact or non-intact PERISWOUND desirable?

A

Intact

34
Q

Define MACERATED

A

Appears wet and too hydrated

35
Q

What does MACERATED indicate?

A

Increased risk of damage, needs moisture control.