Week 2: Wound Assessment Flashcards
Definition
Fluid that is red and contains blood. It indicates active bleeding or recent trauma to the wound.
Define
Sanguineous Exudate
Define
Collagen
A protein that provides structural support to tissues and is a key component of the extracellular matrix in wound healing.
Definition
The density and health of blood vessels in the wound area, which impacts the delivery of oxygen and nutrients essential for healing.
Define
Vascularity
Define
Hypoxia
A condition where there is a deficiency of oxygen in the tissues, which can impede wound healing.
Define
Cavity
A space within the wound bed that may need to be filled for proper healing.
Definition
A passage that extends under the skin from the wound surface to deeper tissues.
Tunnelling
Definition
A type of chronic wound that occurs in people with diabetes, often due to nerve damage and poor circulation.
Define
Diabetic Foot Ulcer
Definition
New tissue that forms over a wound during the healing process, characterized by a reddish, bumpy appearance and a rich supply of blood vessels.
Define
Granulation Tissue
Define
Pressure Ulcer
A wound caused by prolonged pressure on the skin, often found in areas over bony prominences. Also known as a bedsore or decubitus ulcer.
Define
Arterial Ulcer
A wound that results from poor blood flow in the arteries, often located on the feet or lower legs.
Definition
The area of tissue within the wound where healing occurs, including granulation tissue and any remaining necrotic tissue.
Define
Wound Bed
Definition
A protein that provides structural support to tissues and is a key component of the extracellular matrix in wound healing.
Define
Collagen
Definition
Dead tissue that is often dark, dry, and leathery. It can be black or brown and impedes the healing process by preventing new tissue from forming.
Define
Necrotic Tissue
Definition
The perimeter of the wound. Assessing the edges helps determine if the wound is healing correctly and if new tissue is forming.
Define
Wound Edges
Definition
The process where new epithelial cells grow over the wound bed, covering the wound with new skin.
Define
Epithelialization
Define
Purulent Exudate
Thick, yellow, green, or brown fluid containing pus, indicating infection or inflammation.
Define
Tunnelling
A passage that extends under the skin from the wound surface to deeper tissues.
Definition
A structured approach to wound assessment that stands for Tissue, Inflammation/Infection, Moisture, Edges, and Surrounding Skin.
Define
T.I.M.E.S. Framework
Define
Wound Culture
A test used to identify microorganisms present in a wound to determine the appropriate antibiotic treatment.
Define
Slough
A layer of dead tissue that may be yellow, gray, or brown and is loosely attached to the wound bed. It often needs to be removed for proper healing.
Define
Venous Ulcer
A type of chronic wound that occurs due to poor blood flow in the veins, typically found on the lower legs and ankles.
Definition
Fluid that leaks out of blood vessels into the surrounding tissues during the inflammatory phase of wound healing. It can be clear, bloody, or pus-like.
Define
Exudate
Definition
A space within the wound bed that may need to be filled for proper healing.
Define
Cavity
Define
Debridement
The process of removing dead or infected tissue from a wound to promote healing and prevent infection.
Define
Sanguineous Exudate
Fluid that is red and contains blood. It indicates active bleeding or recent trauma to the wound.
Definition
A narrow channel or tract that can extend from the wound to deeper tissues.
Define
Sinus
Definition
An imaging technique where a radiopaque dye is injected into a wound to visualize tunnelling, sinuses, or fistulas.
Define
Sinogram
Definition
A slimy layer of microorganisms that adheres to the wound surface and can make infection harder to treat.
Define
Biofilm
Define
Exudate
Fluid that leaks out of blood vessels into the surrounding tissues during the inflammatory phase of wound healing. It can be clear, bloody, or pus-like.
Define
Granulation Tissue
New tissue that forms over a wound during the healing process, characterized by a reddish, bumpy appearance and a rich supply of blood vessels.
Definition
A condition where there is a deficiency of oxygen in the tissues, which can impede wound healing.
Define
Hypoxia
Definition
A wound that results from poor blood flow in the arteries, often located on the feet or lower legs.
Define
Arterial Ulcer
Define
T.I.M.E.S. Framework
A structured approach to wound assessment that stands for Tissue, Inflammation/Infection, Moisture, Edges, and Surrounding Skin.
Define
Necrotic Tissue
Dead tissue that is often dark, dry, and leathery. It can be black or brown and impedes the healing process by preventing new tissue from forming.
Define
Doppler Device
A tool used to measure blood flow and detect the presence of arterial or venous disease by using sound waves.
Define
Wound Bed
The area of tissue within the wound where healing occurs, including granulation tissue and any remaining necrotic tissue.
Define
Epithelialization
The process where new epithelial cells grow over the wound bed, covering the wound with new skin.
Define
Wound Edges
The perimeter of the wound. Assessing the edges helps determine if the wound is healing correctly and if new tissue is forming.
Definition
A tool used to measure blood flow and detect the presence of arterial or venous disease by using sound waves.
Define
Doppler Device
Define
Sinus
A narrow channel or tract that can extend from the wound to deeper tissues.
Define
Biofilm
A slimy layer of microorganisms that adheres to the wound surface and can make infection harder to treat.
Define
Serous Exudate
A type of clear, thin fluid that is typically associated with mild inflammation and helps to keep the wound moist.
Define
Wound Margin
The border or boundary of the wound, which includes the edges and surrounding skin.
Define
Vascularity
The density and health of blood vessels in the wound area, which impacts the delivery of oxygen and nutrients essential for healing.
Define
Diabetic Foot Ulcer
A type of chronic wound that occurs in people with diabetes, often due to nerve damage and poor circulation.
Definition
A type of clear, thin fluid that is typically associated with mild inflammation and helps to keep the wound moist.
Define
Serous Exudate
Define
Sinogram
An imaging technique where a radiopaque dye is injected into a wound to visualize tunnelling, sinuses, or fistulas.
Definition
The process of removing dead or infected tissue from a wound to promote healing and prevent infection.
Define
Debridement
Definition
The border or boundary of the wound, which includes the edges and surrounding skin.
Define
Wound Margin
Definition
A test used to identify microorganisms present in a wound to determine the appropriate antibiotic treatment.
Define
Wound Culture
Definition
Thick, yellow, green, or brown fluid containing pus, indicating infection or inflammation.
Define
Purulent Exudate
Definition
A wound caused by prolonged pressure on the skin, often found in areas over bony prominences. Also known as a bedsore or decubitus ulcer.
Define
Pressure Ulcer
Definition
A layer of dead tissue that may be yellow, gray, or brown and is loosely attached to the wound bed. It often needs to be removed for proper healing.
Define
Slough
Definition
A type of chronic wound that occurs due to poor blood flow in the veins, typically found on the lower legs and ankles.
Define
Venous Ulcer
What is the key characteristic of an acute wound?
Healing occurs in a timely and organized manner with clean, intact edges and typically heals without complications.
What is a chronic wound?
A wound where healing is delayed (more than 6 weeks) and does not follow a timely, orderly process.
Name a physical factor that affects wound healing.
Nutritional status
Oxygenation
Infection Control
Wound Environment
Why is oxygenation important for wound healing?
Proper blood flow and oxygen delivery are crucial for healing.
What psychosocial factor can impact wound healing?
Emotional state
social support
How can cognitive function affect wound healing?
Understanding and adherence to wound care instructions are important.
What should be documented during a wound assessment?
Wound size, depth, edges, and exudate.
Why is establishing a baseline evaluation important?
To track healing progress over time.
What does ongoing assessment involve?
Regular evaluations to monitor changes and adapt management plans.
What impact can chronic diseases have on wound healing?
They can impair wound healing due to poor circulation, altered immune responses, or impaired tissue regeneration.
How does aging affect wound healing?
Aging can result in slower healing times and increased risk of complications due to affected skin integrity and repair processes.
What issues might obesity cause in wound healing?
Poor circulation and increased risk of infection.
How can emaciation impact wound healing?
Insufficient nutritional reserves can affect healing capacity.
Why is protein important for wound healing?
Essential for tissue repair and immune function.
Which vitamins and minerals are crucial for wound healing?
Vitamins A, C, and zinc.
How can immunosuppressive medications affect wound healing?
They can hinder the body’s ability to fight infections and repair tissue.
How does infection affect wound healing?
Presence of bacteria or other pathogens can delay healing and increase tissue damage.
Why is moisture balance important in wound care?
Both excessive moisture and dryness can impair healing.
What effect can anticoagulants have on wound healing?
They can affect clotting and increase bleeding risk.
How might steroids impact wound healing?
They may reduce inflammation but can also impair wound healing.
What negative effects can alcohol abuse have on wound healing?
Impaired immune function and overall health.
How does smoking affect wound healing?
It reduces blood flow and oxygen delivery to tissues, slowing healing.
What effect can radiation therapy have on wound healing?
It can damage healthy tissues and affect wound repair.
How can a lack of social support impact wound healing?
It can affect wound care and healing outcomes.
In what way can socioeconomic status influence wound healing?
Limited resources may affect the ability to obtain necessary wound care supplies and treatments.
How can psychological stress impact wound healing?
It can impair immune function and exacerbate healing issues.
What influence can mental health conditions have on wound healing?
Depression and anxiety can influence self-care practices and overall health.
How does psychological stress impact physiological responses related to wound healing?
It can trigger physiological responses that hinder wound healing by affecting hormone levels, immune function, and overall health.
What is the purpose of case scenarios and workshops in understanding wound healing factors?
They help illustrate how intrinsic and extrinsic factors affect wound healing and provide practical examples of managing these factors in clinical settings.
What is the goal of the Assessment phase in the A-B-C-D-E approach?
To establish a baseline for treatment and identify factors that might impact healing.
What does the Wound Assessment involve?
Comprehensive evaluation of the wound’s size, depth, edges, and exudate.
What is included in the Patient Assessment?
A full review of the patient’s medical history, psychosocial factors, and overall health status.
What are Evidence-Based Practices used for in the Best Practice phase?
To determine the most effective treatments and interventions for the wound based on current research and guidelines.
What should the Treatment Plan in the Best Practice phase include?
Appropriate dressings, debridement methods, and infection control measures.
What does the Control Factors phase focus on?
Identifying intrinsic and extrinsic factors that might impede healing and implementing strategies to control or mitigate these factors.
Give an example of an intrinsic factor that might be controlled in the Control Factors phase.
Poor nutrition.
What is the purpose of Documentation in the A-B-C-D-E approach?
To ensure continuity of care, facilitate communication within the healthcare team, and provide a record for evaluating treatment effectiveness.
What should be included in the Documentation phase?
Detailed and accurate records of the wound assessment, treatment plan, and progress.
What is the focus of the Evaluation phase?
Ongoing assessment of the wound’s progress and the effectiveness of the treatment plan.
How are adjustments made in the Evaluation phase?
Based on the wound’s response to treatment and any changes in the patient’s condition.
Why is regular evaluation important in wound management?
To ensure that the treatment plan remains effective and to make necessary adjustments based on the wound’s progress and patient’s condition.
Why are investigations important in wound management?
To confirm wound aetiology, identify underlying physical elements, check for poor nutrition, and confirm infection or other issues.
What is the purpose of confirming wound aetiology?
To determine the cause of the wound.
Why is it necessary to identify underlying physical elements?
To assess conditions that may affect wound healing.
What does checking for poor nutrition involve?
Evaluating nutritional status to support healing.
Why is confirming infection crucial?
To diagnose infection or other complications that might impede healing.
What is the purpose of measuring oxygen saturation?
To assess if the patient is receiving adequate oxygenation for tissue repair.
What is the normal range for oxygen saturation?
> 95% saturation.
Why are random blood sugar readings taken?
To detect impaired glucose metabolism that may affect wound healing.
What might elevated glucose levels indicate in wound management?
Poor wound healing and increased infection risk.
What is assessed during a peripheral vascular assessment?
Blood flow and circulation in affected limbs.
What techniques are used in peripheral vascular assessment?
Inspection, palpation, and auscultation.
What is the purpose of the Ankle Brachial Pressure Index (ABPI)?
To measure arterial perfusion in the lower limbs and predict the severity of peripheral arterial disease.
What is a limitation of the ABPI?
It does not identify specific blood vessel blockages.
What does the Monofilament 10g test assess?
Peripheral neuropathy, especially in diabetic patients.
What information does a Full Blood Count/Examination (FBC/E) provide?
Hemoglobin levels and white cell counts to assess oxygen carrying capacity and infection or immunosuppression.
What do Random Blood Glucose and HbA1c tests detect?
Undiagnosed diabetes and uncontrolled blood glucose levels.
What do C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) measure?
Inflammation and infection markers.
What do renal function tests assess?
Kidney function, including levels of urea, creatinine, and electrolytes.
Why are liver function tests important in wound assessment?
They assess liver health and protein synthesis capabilities.
What do Vitamins/Elements tests measure?
Levels of iron, vitamins B12 and D, zinc, selenium, and folate.
What is the purpose of wound swabs?
To identify specific organisms in infected wounds.
What do radiological tests like ultrasound and plain X-rays detect?
Collections, cavities, foreign bodies, and osteomyelitis.
How does a Duplex Ultrasound of Lower Limbs assist in wound management?
It measures pressure, flow, waveform patterns, volume changes, venous reflux, and calf muscle pump efficiency.
What does a Sinogram identify?
Tunnelling, fistulae, or sinuses in wounds.
What is the purpose of biopsies in wound management?
To investigate atypical wounds, unusual locations, or non-responsiveness to therapy.
What distinguishes an acute wound from a chronic wound?
Acute wounds typically heal within 3-4 weeks, while chronic wounds take more than 6 weeks and may have delayed healing due to ongoing factors.
What should be documented when assessing the location of a wound?
The anatomical position and landmarks of the wound.
Why is it important to measure a wound?
To document the wound’s size, depth, and changes over time.
What are the key measurements to document for a wound?
Surface area, length, width, depth, and presence of any cavities, sinuses, or tunnelling.
What does the “T” in the T.I.M.E.S. framework stand for?
TISSUE
What should you identify when assessing tissue in a wound?
Type of tissue (granulation, necrotic, slough), tissue viability, and its colour and texture.
How can you determine if the tissue in the wound bed is viable?
By assessing if the tissue is living or dead based on its appearance and response to treatment.
What are the signs of inflammation versus infection in a wound?
Inflammation includes erythema, heat, oedema, and pain; infection signs include increased exudate, pain, odour, and delayed healing.
What is biofilm, and why is it significant in wound management?
Biofilm is a slimy layer of microorganisms that complicates healing and resists treatment.
What should you assess when evaluating moisture in a wound?
Colour, consistency, odour, and amount of exudate.
What does the “E” in the T.I.M.E.S. framework refer to?
EDGES
Why is it important to assess the edges of a wound?
To evaluate granulation and epithelialization, which are crucial for wound healing.
What should be assessed regarding the surrounding skin of a wound?
The condition of the skin around the wound and any signs of infection or abnormalities.
How should pain be assessed in wound management?
By evaluating severity, type, and frequency of pain.
What should be included in wound documentation?
Patient assessment, investigations, wound assessment chart, care plan, interventions, and progression.
Why is accurate documentation essential in wound management?
To ensure continuity of care, facilitate communication, and track changes and effectiveness of treatments.
What are some potential complications that could affect wound healing?
Infection, inadequate nutrition, poor circulation, and biofilm formation.
What is the clock face method used for in wound measurement?
It is used to orient the wound for measuring length and width, with specific directions (e.g., heel to toes for foot wounds, head to feet for general wounds).
How should you measure the width of a wound?
Measure at right angles to the length, identifying the widest part of the wound.
What is the definition of wound depth?
The distance from the visible surface of the wound to the deepest point.
Which tool is commonly used to measure the depth of a wound?
A cotton tip applicator.
What should you do to ensure accurate depth measurements?
Take several measurements in different areas of the wound.
How should cavities or sinus tracts within a wound be measured?
Use a cotton tip applicator to probe gently and record the direction and depth.
What is wound tracing, and why is it used?
Wound tracing is creating a visual representation of the wound to track changes in size and shape over time.
How can you create a visual representation of a wound for tracing?
Use templates, or place a clear cover or cling film over the wound, then trace the outline onto the film or dressing pack.
What are some additional tips for accurate wound measurement?
Measure dimensions consistently at each dressing change, use sterile tools, and ensure the wound area is clean.
Why is it important to document wound measurements accurately?
Accurate documentation helps in tracking healing progress, assessing treatment effectiveness, and making necessary adjustments to the care plan.
Pink, red, yellow and black tissues is called what, respectively?
Pink - epithleial
Red - granulation
Yellow - slough
Black - necrotic
Symptoms of inflammation include:
Erythema
Heat
Oedema
Pain
Symptoms of infection include:
Delayed healing
Malodour
Development of biofilm
Increased exudate
What are some ways we describe the surrounding skin?
Intact
Erythema
Macerated
Oedematous
Dermititis
What are some types of wound edges?
Level
Raised
Undermined
Tunnelled
Rolled
Identify the tissue type
Epithelial
Is this tissue viable or non-viable?
Viable
Identify the tissue type
Granulation
Viable or non-viable?
Viable
Identify the tissue type
Slough
Viable or non-viable
non-viable
Identify the tissue type
Necrotic
Viable or non-viable?
Non-viable
What are the 5 stages of biofilm development?
- Attachment
- Cell-to-cell adhesion
- Proliferation
- Maturation
- Dispersion
Describe the attachment stage of biofilm development
Planktonic (free-floating) bacteria adhere to the biomaterial surface
Describe the cell-to-cell adhesion stage of biofilm development
Cells aggregate, form micro colonies and excrete extracellular polymeric substances
Describe the proliferation stage of biofilm development
A biofilm is formed and matures, and the cells form multilayered clusters. Further maturation of the biofilm provides protection against host defence mechanisms and antibiotics
Describe the maturation stage of biofilm development
The biofilm reaches a critical mass
Describe the Dispersion stage of biofilm development
Dispersal of planktonic bacteria, ready to colonise other surfaces
Which of the following best describes an acute wound?
A. Heals within a predictable time frame and is typically caused by a specific event
B. Persists beyond the expected healing time and may be due to underlying conditions
C. Always involves chronic inflammation
D. Is only associated with surgical procedures
A. Heals within a predictable time frame and is typically caused by a specific event
Chronic wounds are characterized by:
A. Rapid healing and minimal complications
B. Healing that exceeds the normal time frame, often with ongoing inflammation
C. Immediate closure with minimal intervention
D. Complete absence of microbial contamination
B. Healing that exceeds the normal time frame, often with ongoing inflammation
Which of the following is a common feature of chronic wounds?
A. Complete resolution within a few days
B. Presence of granulation tissue and re-epithelialization
C. Prolonged inflammation and delayed healing
D. Immediate pain relief and resolution
C. Prolonged inflammation and delayed healing
The primary goal of wound assessment is to:
A. Determine the patient’s insurance coverage
B. Identify the specific cause of the wound
C. Evaluate the wound’s characteristics and plan appropriate care
D. Predict the exact time frame for healing
C. Evaluate the wound’s characteristics and plan appropriate care
Which of the following is NOT a key principle of wound management?
A. Keeping the wound dry at all times
B. Assessing the wound regularly for changes
C. Selecting appropriate dressings based on wound characteristics
D. Ensuring patient comfort and pain control
A. Keeping the wound dry at all times
What should be considered when developing a wound management plan?
A. The patient’s lifestyle and comorbid conditions
B. The availability of the latest technology only
C. Patient’s ability to afford the most expensive treatments
D. The number of wounds present
A. The patient’s lifestyle and comorbid conditions
The ‘T’ in T.I.M.E.S stands for:
A. Tissue type
B. Temperature of the wound
C. Time of the wound
D. Treatment frequency
A. Tissue type
Which element of T.I.M.E.S refers to the management of excessive moisture and exudate?
A. Tissue type
B. Infection
C. Moisture balance
D. Edge of the wound
C. Moisture balance
The ‘S’ in T.I.M.E.S relates to:
A. Size of the wound
B. Surrounding skin condition
C. Surgical history
D. Sensitivity to dressings
B. Surrounding skin condition
Which tissue type is characterized by a shiny, red appearance and indicates healthy granulation tissue?
A. Necrotic tissue
B. Slough
C. Eschar
D. Granulation tissue
D. Granulation tissue
What type of tissue is commonly yellow, moist, and often found in chronic wounds?
A. Granulation tissue
B. Slough
C. Necrotic tissue
D. Eschar
B. Slough
Eschar is typically described as:
A. Soft, moist tissue that is easily removed
B. Hard, dry, and black tissue
C. Red, beefy tissue indicating new growth
D. Yellowish tissue with a slimy texture
B. Hard, dry, and black tissue
Which type of tissue indicates a lack of blood supply and is often associated with the need for debridement?
A. Granulation tissue
B. Slough
C. Necrotic tissue
D. Healthy epithelial tissue
C. Necrotic tissue
The peri-wound skin is important to assess because:
A. It determines the size of the wound
B. It helps in identifying infection and maceration
C. It is not related to wound healing
D. It indicates the type of dressing required
B. It helps in identifying infection and maceration
Which condition of the peri-wound skin suggests excessive moisture exposure?
A. Dry, flaky skin
B. Redness and swelling
C. Hardened, calloused areas
D. Normal skin tone and texture
B. Redness and swelling
Healthy peri-wound skin should appear:
A. Dry and cracked
B. Red and inflamed
C. Smooth and intact
D. Yellow and moist
C. Smooth and intact
Maceration of the peri-wound skin can lead to:
A. Improved healing
B. Increased risk of infection
C. Decreased wound size
D. Enhanced tissue regeneration
B. Increased risk of infection
Which type of exudate is thin, clear, and typically seen in early stages of healing?
A. Serous
B. Sanguineous
C. Serosanguineous
D. Purulent
A. Serous
A purulent exudate is characterized by:
A. Clear and thin fluid
B. Red, bloody fluid
C. Thick, yellow or green fluid
D. Pink, watery fluid
C. Thick, yellow or green fluid
Which type of exudate is often associated with infection and has a foul odor?
A. Serous
B. Sanguineous
C. Serosanguineous
D. Purulent
D. Purulent
Management of serous exudate typically involves:
A. Using highly absorbent dressings
B. Applying antimicrobial agents
C. Monitoring for infection signs
D. Regularly changing dressings to prevent maceration
D. Regularly changing dressings to prevent maceration
Acute wound infection is typically characterized by:
A. Persistent redness and swelling
B. Sudden onset with signs of redness, warmth, and purulent drainage
C. Long-term presence of biofilm
D. Minimal pain and discomfort
B. Sudden onset with signs of redness, warmth, and purulent drainage
Chronic wound infection may be indicated by:
A. Rapid resolution of symptoms
B. Persistent inflammation and non-healing despite treatment
C. Immediate improvement after antibiotic therapy
D. Complete absence of any signs of infection
B. Persistent inflammation and non-healing despite treatment
Biofilm in a wound is characterized by:
A. A single layer of bacteria with no protective barriers
B. A complex community of bacteria embedded in a protective matrix
C. Complete absence of microbial organisms
D. Rapid clearance of bacteria by the immune system
B. A complex community of bacteria embedded in a protective matrix
A key difference between acute and chronic infections is:
A. Acute infections show no response to antibiotics
B. Chronic infections have a longer duration with ongoing symptoms
C. Acute infections are less severe than chronic infections
D. Chronic infections resolve within a few days
B. Chronic infections have a longer duration with ongoing symptoms
Biofilm formation can:
A. Enhance the wound healing process
B. Protect bacteria from the immune system and antibiotics
C. Facilitate rapid wound closure
D. Prevent chronic inflammation
B. Protect bacteria from the immune system and antibiotics
The presence of biofilm in a wound typically requires:
A. Standard wound cleaning with saline
B. Use of specific antibiotics and wound debridement strategies
C. Immediate surgical intervention
D. No treatment as biofilm is harmless
B. Use of specific antibiotics and wound debridement strategies
Which of the following is NOT a standard element of wound measurement?
A. Length and width
B. Depth
C. Color of the wound bed
D. Volume of exudate
D. Volume of exudate
The depth of a wound is measured to:
A. Determine the need for pain management
B. Assess the extent of tissue damage and guide treatment
C. Evaluate the amount of exudate
D. Monitor the rate of healing
B. Assess the extent of tissue damage and guide treatment
