Module 7- Exam: wound bed color, drainage, edges

Question 1

What are the 4 types of drainage/exudate

Answer 1

1. sanguineous
2. serosanguinous
3. serous
4. purulent

Question 2

Describe Sanguineous drainage

Answer 2

thin, bright red

Question 3

Describe Serosanguinous drainage

Answer 3

thin, watery, pale red to pink

Question 4

Describe serous drainage

Answer 4

thin, watery clear

Question 5

Describe purulent drainage

Answer 5

thick or thin, opaque tan to yellow (infection)

Question 6

Describe foul purulent drainage

Answer 6

thick opaque yellow to green with offensive odor- very concerned about infection

Question 7

Amount of drainage describe
none
scant
small
moderate
large

Answer 7

none-wound dry
scant- wound tissue moist, no measurable drainage
small- wound tissue very moist, drainage <25% of dressing
moderate- wound tissue is wet, drainage involves 25-75% of dressing
large- wound tissue filled with fluid involves >75% dressing

Question 8

during a wound exam where do you want to check the pulse

Answer 8

compare side to side
above and below

Question 9

during a wound exam what other areas should you take into consideration

Answer 9

skin temperature

blisters, calluses
skin color
hair/nail growth
moisture
texture
general visual assessment

Question 10

______- indicates the type of wound or the healing process occurring in the wound bed

Answer 10

wound edges

Question 11

If a wound edge is even this is typical for a what type of wound

Answer 11

arterial wound

Question 12

if a wound edge is irregular this is typical for what type of wound

Answer 12

venous wound
may occur as the wound epithelializes

Question 13

what is rolling of wound edges a sign of

Answer 13

halted healing process
cells are termed senscent, meaning they are unable to reproduce

Question 14

The rolled edge is termed _____

Answer 14

epibole

Question 15

What is hyperkeratosis of a wound edge

Answer 15

overdevelopment of the horny layer of the skin
appears as a thickened skin around the edge of a wound or as a callus

Question 16

what is macerated edges a result of and what could it mean for the wound healing process

Answer 16

a result of too much moisture
can slow healing process
creates a high risk of infection/wound becoming larger

Question 17

What is a dehisced wound

Answer 17

wound edges come apart that were once together
may be the superficial layers only
or can open full depth

Question 18

deep pain- craping indicative of ____ more comfortable in dependent position

Answer 18

ischemia or hypoxia

Question 19

throbbing, localized pain- indicative of ____

Answer 19

infection

Question 20

deep pain that increases with pressure may be indicative of ____

Answer 20

osteomyelitis

Question 21

superficial tenderness- exposed _____ may be accompanied by sharp shooting pains

Answer 21

nerve endings

Question 22

pain with stimulation of red tissue- _____

Answer 22

living muscle

Question 23

what are some examples of vascular testing: arterial

Answer 23

pulses- compare side to side above and below
doppler- for pulses that are not palpable
ABI-ankle brachial index

Question 24

local signs of infection: pus, change in color, characteristics of exudates, redness, induration, changes in wound odor what should you do

Answer 24

wound culture

Question 25

what should you do if you notice systemic signs of infection, fever, leukocytosis

Answer 25

wound culture

Question 26

elevated glucose
pain in neuropathic extremity
lack of healing after 2 weeks in a clean wound despite optimal care

Answer 26

get a wound culture

Question 27

what does DIMES stand for

Answer 27

Debridement
Infection/inflammation
Moisture balance
Edges
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