Week 1 Wound Exam

Question 1

how do we get a patient history

Answer 1

from the patient, their medical records, and information from the family and caretakers too

Question 2

what kind of things do we want to know in our history

Answer 2

lifestyle and function
living situation
prior and current level function
employment
health habits (smoking, alcohol, nutrition, sleep, stress)
past and current medical history (systems, medications and allergies)

Question 3

what do we want to know about the wound

Answer 3

acute or chronic 
how did they get it 
had any tests? (cultures, labs)
has it improved? worse?
pain?
others in the past?
dressing? when do you change it?

Question 4

how do we examine the location

Answer 4

use terminology to describe the location on the body, and be very specific . also use a body chart, drawings, pictures, and assign numbers if multiple wounds

Question 5

how do we examine size

Answer 5

• can measure length, width and depth
• can also use clock method (the area closest to the head is 12, and you measure length 12-6, width, 9-3 and depth at different locations
• can also use pictures, volumetric and tracings, and describe the total body area

Question 6

what do we want to identify in the wound bed

Answer 6

the tissue type present

Question 7

what is granulation tissue

Answer 7

temporary vascularized scaffolding, that is beefy and red, or could be pale and dusky if poor blood supply or infection

Question 8

what is non-viable necrotic tissue

Answer 8

dead,

Question 9

different between slough and eschar

Answer 9

slough is yellow or tan and stringy and mutinous

eschar is black necrotic tissue, that is soft or hard, wet or dry

Question 10

what is undermining

Answer 10

the tissue under the wound edge is gone. So much so that you can waggle the tip of a q-tip under the edge.

Question 11

how would you document undermining

Answer 11

there is undermining 4cm from the 10-12 position

Question 12

what is a tract

Answer 12

marrow passageway that is a tube like extension of the wound

Question 13

documentation of a tract

Answer 13

tract at 5 o’clock, that is 7cm

Question 14

what is a tunnel

Answer 14

has an entrance and exit

Question 15

what kinds of things do we want to observe when looking at wound edges

Answer 15

are they well defined or defuse, are they thick or thin, are they attached to the wound base of raises or rolled (epibole), color and do we have epithelialization

Question 16

epibole

Answer 16

rolling of a wound edge

Question 17

what is serous drainage

Answer 17

protein rich fluid with white blood cells that is clear-pale yellow and watery

Question 18

what is sanguineous drainage

Answer 18

blood or drying blood. red-dark brown and it has the consistency of blood or thickened water

Question 19

what is purulent drainage

Answer 19

infection!

this is white and pale yellow and creamy

Question 20

how do we want to describe drainage

Answer 20

type, color, consistency, amount, and when it was last dressed.

Question 21

when do we assess odor

Answer 21

right after irrigation

Question 22

what can cause an odor

Answer 22

infection
non-viable tissue
old dressing
hot weather

Question 23

what is the peri wound

Answer 23

the area around the wound.

Question 24

what do we want to examine with the peri wound

Answer 24

• palpate around it for edema, temperature, induration.
• maceration, healthy, dry, peeling…?
• skin color texture, dry, hair
• callus
• S/S infection
• sensation
• circulation