Module 2: Wound Assessment Flashcards
What is the first thing you must know for a proper WOUND assessment? Why?
The ETIOLOGY of the WOUND, understanding the WOUND will help you to make an effective care plan
Where can surgical dehiscence and trauma (skin tears) occur?
Anywhere on the body
WOUND location _________ to WOUND ETIOLOGY
corresponds
Where are PRESSURE ULCERS normally found?
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
What types of ULs are common in the lower legs?
ARTERIAL and VENOUS
Why do ART ULs occur?
Poor blood flow, restricted amount of oxygenated blood results in harm to tissues, in this case, ULs
Why do VEN ULs occur?
Difficulty flowing back up the heart for proper circulation (pooling of blood in legs).
Why does EDEMA occur with VEN ULs?
Because valves in the VEINS are not working properly for circulation and the fluid builds up = EDEMA
“Mixed VENOUS ARTERIAL” indicates:
A combination of VEN and ART ULs
What causes NEUROPATHIC/DIABETIC ULs?
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.
Where are NEUROPATHIC/DIABETIC ULs normally found?
PLANTAR surface of the foot
What characteristic of a WOUND should you be assessing weekly?
(know at least 4)
- pain
- size,
- wound bed
- exudate
- edge
- odour
- Peri-wound skin
What are 3 benefits of involving pts in the WOUND care?
- Allows some Control
- Reduces Anxiety
- Adheres to Careplan
How can uncontrolled pain affect infct and healing?
Increases the risk of infct and delays healing
Why is WOUND measurement important?
This allows you to monitor progress objectively (good vs bad)
Define UNDERMINING
- 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
Define SINUS TRACT
A channel that extends in any part of wound base and tracts into deeper tissue.
If a WOUND were described as at “12 o’clock” what would this indicate?
That this is a head WOUND. 12 o’clock = head of the patient, 6 o’clock = feet.
What is the expected healing rate of a WOUND (in %)
20-40% in 2-4 weeks.
Characteristics of ESCHAR:
- Dry
- Dead Tissue
- Black or brown
Characteristics of SLOUGH:
- Dry or wet
- Loose or firmly attached yellow or brown dead tissue
- Moisture added to wound facilitates this process.
T or F:
GRANULATION TISSUE is undesirable during the healing process
F, it is desirable, this is new tissue
What does GRANULATION TISSUE look like?
Firm red and moist pebbled healthy tissue
Is superficial pink, red tissue also desirable for healing?
Yes
