Skin Examination & Wound Assessment

Question 1

What is turgor?

Answer 1

indication of extent of dehydration or fluid loss

Question 2

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

Answer 2

• 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

Question 3

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

Answer 3

pressure injuries

Question 4

What does the Braden Scale assess?

Answer 4

risk of formation of pressure injury

Question 5

what does the Bates-Jensen Wound assessment tool assess?

Answer 5

all wound types & monitors healing

Question 6

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

Answer 6

through epidermis

Question 7

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

Answer 7

epidermis and part of dermis

Question 8

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

Answer 8

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

Question 9

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

Answer 9

• 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

Question 10

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

Answer 10

pressure injury

Question 11

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

Answer 11

diabetic/neuropathic ulcer

Question 12

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

Answer 12

venous wound

Question 13

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

Answer 13

arterial wound

Question 14

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

Answer 14

pressure

Question 15

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

Answer 15

shear or friction

Question 16

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

Answer 16

venous

Question 17

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

Answer 17

trauma or friction

Question 18

how is the perpendicular method to measuring a wound performed?

Answer 18

length (cm) X Width (cm)

Question 19

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

Answer 19

• patient head is 12
• patient feet is 6

Question 20

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

Answer 20

• heel = 12
• toes = 6

Question 21

What is undermining?

Answer 21

tissue destruction underlying intact skin along the wound margins

Question 22

What is tunneling?

Answer 22

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

Question 23

What forces cause both tunneling and undermining?

Answer 23

shear

Question 24

How is the tracing method performed?

Answer 24

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

Question 25

What are the pros to tracing method?

Answer 25

- 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

Question 26

what are the cons of the tracing method?

Answer 26

- may damage or contaminate the wound - pain or discomfort for the patient - more time required

Question 27

What is the pros to photography?

Answer 27

- permanent documentation - relatively easy - visualization of various tissue types seen in the wound bed - good inter observer reproducibility

Question 28

What are the cons to photography?

Answer 28

- always be consistent - HIPPA concerns

Question 29

What is slough?

Answer 29

hydrated necrotic tissue

Question 30

How does slough present?

Answer 30

- yellow, grey, tan or brown - soft, thin, fibrinous, stringy or mucinous

Question 31

Where is slough often found?

Answer 31

under eschar as a result of body's autolytic processes

Question 32

What is eschar?

Answer 32

- composed of dead skin of subcutaneous cells - necrotic

Question 33

How does eschar present?

Answer 33

- firm, dry, leathery, black or brown

Question 34

What does eschar become as it softens?

Answer 34

slough

Question 35

T/F: Eschar is a scab

Answer 35

false

Question 36

How does granulation appear?

Answer 36

- beefy, deep red - puffy or bubble appearance

Question 37

How does epithelial tissue present?

Answer 37

- deep pink to pearly pink - light purple around the edges in a full thickness wound - epithelial islands or bridging

Question 38

What is hyper granulation tissue?

Answer 38

granulation that forms above the surface of the surrounding epithelium

Question 39

How does hyper granulation tissue affect healing?

Answer 39

- delays epithelialization - impedes healing

Question 40

How does serous drainage present? When is it normal?

Answer 40

- thin & watery plasma - normal in acute inflammatory phase

Question 41

How does sanguinous present? when is it normal?

Answer 41

- bloody (fresh bleeding) - small amount normal in acute inflammatory phase

Question 42

How does serosanguinous drainage present?

Answer 42

- thin, watery, pale red to pink, plasma with RBS's

Question 43

How does seropurulent drainage present?

Answer 43

thin, watery, cloudy, yellow, tan

Question 44

How does purulent drainage present? When is it normal?

Answer 44

- thick, opaque, tan, yellow, green or brown - never normal

Question 45

What is epibole?

Answer 45

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

Question 46

How is epibole treated?

Answer 46

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

Question 47

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

Answer 47

- serous - often considered normal - may be staph infection (depends on amount)

Question 48

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

Answer 48

infection or inflammation

Question 49

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

Answer 49

indicates capillary damage

Question 50

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

Answer 50

presence of wound slough

Question 51

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

Answer 51

may be due to silver containing dressing

Question 52

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

Answer 52

no odor

Question 53

What odor does pseudomonas have?

Answer 53

sweet smell with green drainage

Question 54

What type of odor does necrotic tissue have?

Answer 54

dead odor

Question 55

What type of odor does malignant tissue have?

Answer 55

wet cardboard

Question 56

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

Answer 56

- tissue it moist - no measurable amount of exudate

Question 57

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

Answer 57

- tissue is wet - moisture evenly distributed throughout the wound - on less than or equal to 25% of the dressing

Question 58

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

Answer 58

- tissue is saturate - > 25-75% of the dressing

Question 59

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

Answer 59

- tissue is bathed in fluid - >75% of the dressing