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Integumentary > Skin Examination & Wound Assessment > Flashcards

Skin Examination & Wound Assessment Flashcards

1
Q

What is turgor?

A

indication of extent of dehydration or fluid loss

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2
Q

how can you test turgor and what is the scale break down?

A
  • gently pinch skin & release
  • Immediate return or less than 2 sec = normal turgor (no dehydration)
  • 3 sec or < = poor turgor (moderate to severe dehydration)
  • unable to pinch = severe edema
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3
Q

What type of injuries is the PUSH risk assessment tool for?

A

pressure injuries

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4
Q

What does the Braden Scale assess?

A

risk of formation of pressure injury

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5
Q

what does the Bates-Jensen Wound assessment tool assess?

A

all wound types & monitors healing

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6
Q

When classifying non pressure injury wounds how deep is superficial thickness?

A

through epidermis

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7
Q

When classifying non pressure injury wounds how deep is partial thickness?

A

epidermis and part of dermis

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8
Q

When classifying non pressure injury wounds how deep is full thickness?

A

epidermis, dermis & into subcutaneous tissue (perhaps down to muscle or bone)

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9
Q

For the ankle brachial index: what values indicates:
- calcification/vessel hardening
- normal
- acceptable
- some arterial disease
- moderate arterial disease
- severe arterial disease

A
  • calcification/vessel hardening: >1.4
  • normal: 1.0-1.4
  • acceptable: 0.9-1.0
  • some arterial disease: 0.8-0.9
  • moderate arterial disease: 0.5- 0.8
  • severe arterial disease: <0.5
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10
Q

What type of wound might be found at a bony prominence?

A

pressure injury

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11
Q

What type of wound might be found at a bottom of an insensate foot?

A

diabetic/neuropathic ulcer

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12
Q

What type of wound might be found at the lower leg?

A

venous wound

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13
Q

What type of wound might be found at distal extremities with poor blood flow?

A

arterial wound

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14
Q

If a wound if round and elliptical what type of wound do you suspect it is?

A

pressure

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15
Q

If a wound has jagged edges what type of wound do you suspect it is?

A

shear or friction

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16
Q

If a wound is irregular in shape what type of wound do you suspect it is?

A

venous

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17
Q

If a wound is linear what type of wound do you suspect it is?

A

trauma or friction

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18
Q

how is the perpendicular method to measuring a wound performed?

A

length (cm) X Width (cm)

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19
Q

When using the clock method the patients head is always (blank) o’clock and the feet is (blank) o’clock?

A
  • patient head is 12
  • patient feet is 6
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20
Q

When using the clock method the patients heel is always (blank) o’clock and the toes is (blank) o’clock?

A
  • heel = 12
  • toes = 6
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21
Q

What is undermining?

A

tissue destruction underlying intact skin along the wound margins

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22
Q

What is tunneling?

A

channel extends in any direction from the wound through subcutaneous tissue or muscle

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23
Q

What forces cause both tunneling and undermining?

A

shear

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24
Q

How is the tracing method performed?

A
  • provides 2D outline of wound
  • place tracing device over wound
  • trace the wound
25
Q

What are the pros to tracing method?

A
  • inexpensive & accessible
  • provides a permanent 2D record
  • can be placed in chart
  • length & width can be measure from tracing
  • can do overlay comparisons to reveal extent of healing
  • good inter observer reproducibility
26
Q

what are the cons of the tracing method?

A
  • may damage or contaminate the wound
  • pain or discomfort for the patient
  • more time required
27
Q

What is the pros to photography?

A
  • permanent documentation
  • relatively easy
  • visualization of various tissue types seen in the wound bed
  • good inter observer reproducibility
28
Q

What are the cons to photography?

A
  • always be consistent
  • HIPPA concerns
29
Q

What is slough?

A

hydrated necrotic tissue

30
Q

How does slough present?

A
  • yellow, grey, tan or brown
  • soft, thin, fibrinous, stringy or mucinous
31
Q

Where is slough often found?

A

under eschar as a result of body’s autolytic processes

32
Q

What is eschar?

A
  • composed of dead skin of subcutaneous cells
  • necrotic
33
Q

How does eschar present?

A
  • firm, dry, leathery, black or brown
34
Q

What does eschar become as it softens?

A

slough

35
Q

T/F: Eschar is a scab

A

false

36
Q

How does granulation appear?

A
  • beefy, deep red
  • puffy or bubble appearance
37
Q

How does epithelial tissue present?

A
  • deep pink to pearly pink
  • light purple around the edges in a full thickness wound
  • epithelial islands or bridging
38
Q

What is hyper granulation tissue?

A

granulation that forms above the surface of the surrounding epithelium

39
Q

How does hyper granulation tissue affect healing?

A
  • delays epithelialization
  • impedes healing
40
Q

How does serous drainage present? When is it normal?

A
  • thin & watery plasma
  • normal in acute inflammatory phase
41
Q

How does sanguinous present? when is it normal?

A
  • bloody (fresh bleeding)
  • small amount normal in acute inflammatory phase
42
Q

How does serosanguinous drainage present?

A
  • thin, watery, pale red to pink, plasma with RBS’s
43
Q

How does seropurulent drainage present?

A

thin, watery, cloudy, yellow, tan

44
Q

How does purulent drainage present? When is it normal?

A
  • thick, opaque, tan, yellow, green or brown
  • never normal
45
Q

What is epibole?

A

edges of top layers of epidermis have rolled down to cover the lower edge of epidermis so that epithelial cells cannot migrate from wound edges

46
Q

How is epibole treated?

A

need to re- injure the rolled edges to restart healing process

47
Q

What does it mean if the wound drainage is clear/amber?

A
  • serous
  • often considered normal
  • may be staph infection (depends on amount)
48
Q

What does it mean if the wound drainage is cloudy/milky?

A

infection or inflammation

49
Q

What does it mean if the wound drainage is pink/red?

A

indicates capillary damage

50
Q

What does it mean if the wound drainage is yellow/brown?

A

presence of wound slough

51
Q

What does it mean if the wound drainage is grey/blue?

A

may be due to silver containing dressing

52
Q

What type of odor does clean, non-infected wounds have?

A

no odor

53
Q

What odor does pseudomonas have?

A

sweet smell with green drainage

54
Q

What type of odor does necrotic tissue have?

A

dead odor

55
Q

What type of odor does malignant tissue have?

A

wet cardboard

56
Q

Based on the Bates- Jensen what is the definition of scant wound drainage?

A
  • tissue it moist
  • no measurable amount of exudate
57
Q

Based on the Bates- Jensen what is the definition of small wound drainage?

A
  • tissue is wet
  • moisture evenly distributed throughout the wound
  • on less than or equal to 25% of the dressing
58
Q

Based on the Bates- Jensen what is the definition of moderate wound drainage?

A
  • tissue is saturate
  • > 25-75% of the dressing
59
Q

Based on the Bates- Jensen what is the definition of large wound drainage?

A
  • tissue is bathed in fluid
  • > 75% of the dressing

Integumentary (4 decks)

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