Test and measures for wound healing

Question 1

Wound specific

Answer 1

Location
Dimensions
Tissue type
Wound edges
Drainage
Odor
Periwound skin
Edema

Question 2

Location

Answer 2

Be specific and consist
Medial lateral left right proximal distal

Body chart
Photos
For multiple assign numbers

Question 3

perpendicular ruler, measurement

Answer 3

Length-longest dimension cephalaud to caudal

Width- perpendicular to length at the wounds, widest dimension

depth- deepest point

Undermining always measured using Clock positions

Question 4

clock method

Answer 4

12 o’clock always the area of wound closest to head

length- 12-6
width- 9-3
depth- various

Question 5

granulation tissue

Answer 5

temporary scaffolding of vascularized connective tissue

Healthy granulation is bright beefy red

If pale or dusky blood supply may be poor or maybe infected

Question 6

necrotic or non viable

Answer 6

slough- yellow or tan, stringy or mucinous

eschar- black necrotic tissue, soft or hard, wet or dry, adherent or non adherent

Question 7

undermining

Answer 7

Tissue under wound edge is eroded similar to a cave under the skin

documentation example - undermining of 4 cm from 10 to 12 o’clock

Question 8

sinus tract

Answer 8

Nero passageway tube like extension of wound no exit

Question 9

tunnel

Answer 9

Entrance and exit

Question 10

serous

Answer 10

protein rich fluid with white blood cells
clear pale yellow watery

Question 11

drainage

Answer 11

serous
sanguineous
serosanginous
purulent

Question 12

sanguineous

Answer 12

blood or drying blood
red dark brown, consistency of blood or slightly thickened water

Question 13

purulent

Answer 13

indicator of infection
white pale yellow viscous or creamy consistency

Question 14

periwound

Answer 14

palpation- induration, fluctuance, edema, temp

maceration

skin

callus

sensation

circulation