Module 7- Exam: wound bed color, drainage, edges Flashcards
What are the 4 types of drainage/exudate
- sanguineous
- serosanguinous
- serous
- purulent
Describe Sanguineous drainage
thin, bright red
Describe Serosanguinous drainage
thin, watery, pale red to pink
Describe serous drainage
thin, watery clear
Describe purulent drainage
thick or thin, opaque tan to yellow (infection)
Describe foul purulent drainage
thick opaque yellow to green with offensive odor- very concerned about infection
Amount of drainage describe
none
scant
small
moderate
large
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
during a wound exam where do you want to check the pulse
compare side to side
above and below
during a wound exam what other areas should you take into consideration
skin temperature
blisters, calluses
skin color
hair/nail growth
moisture
texture
general visual assessment
______- indicates the type of wound or the healing process occurring in the wound bed
wound edges
If a wound edge is even this is typical for a what type of wound
arterial wound
if a wound edge is irregular this is typical for what type of wound
venous wound
may occur as the wound epithelializes
what is rolling of wound edges a sign of
halted healing process
cells are termed senscent, meaning they are unable to reproduce
The rolled edge is termed _____
epibole
What is hyperkeratosis of a wound edge
overdevelopment of the horny layer of the skin
appears as a thickened skin around the edge of a wound or as a callus
what is macerated edges a result of and what could it mean for the wound healing process
a result of too much moisture
can slow healing process
creates a high risk of infection/wound becoming larger
What is a dehisced wound
wound edges come apart that were once together
may be the superficial layers only
or can open full depth
deep pain- craping indicative of ____ more comfortable in dependent position
ischemia or hypoxia
throbbing, localized pain- indicative of ____
infection
deep pain that increases with pressure may be indicative of ____
osteomyelitis
superficial tenderness- exposed _____ may be accompanied by sharp shooting pains
nerve endings
pain with stimulation of red tissue- _____
living muscle
what are some examples of vascular testing: arterial
pulses- compare side to side above and below
doppler- for pulses that are not palpable
ABI-ankle brachial index
local signs of infection: pus, change in color, characteristics of exudates, redness, induration, changes in wound odor what should you do
wound culture
what should you do if you notice systemic signs of infection, fever, leukocytosis
wound culture
elevated glucose
pain in neuropathic extremity
lack of healing after 2 weeks in a clean wound despite optimal care
get a wound culture
what does DIMES stand for
Debridement
Infection/inflammation
Moisture balance
Edges
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