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Integumentary > Week 3: Examination of Patients with Open Wounds > Flashcards

Week 3: Examination of Patients with Open Wounds Flashcards

1
Q

What are some things that should be assessed during a cardiovascular/pulmonary systems review?

A

heart rate, blood pressure, respiratory rate, edema, pulse oximetry

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2
Q

What are some things that should be assessed during a musculoskeletal systems review?

A

structure, posture, ROM, strength

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3
Q

What are some things that should be assessed during a neuromuscular systems review?

A

balance, gait, mobility, transfers

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4
Q

What are some things that should be assessed during a gastrointestinal systems review?

A

nutrition intake, supplementation, continence, BMI

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5
Q

What are some nutritional assessment screening tools?

A

Rapid Eating and Activity Assessment for Patients (REAP)

Weight, Activity, Variety, Excess (WAVE)

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6
Q

What are some things that should be assessed during a urogenital systems review?

A

incontinence, poorly controlled diabetes, UTIs

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7
Q

______ is one of the leading causes of skin breakdown?

A

Incontinence

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8
Q

What are some things that should be assessed during an integumentary systems review?

A

skin integrity, skin color, scar formation, hair and nail growth

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9
Q

What is the ability of skin to return to its original shape/condition?

A

turgor

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10
Q

What are some routine integumentary tests and measures?

A

integumentary integrity, circulation (capillary refill), and sensory integrity (monofiliament)

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11
Q

What is the likely cause of a wound on a bony prominence?

A

pressure

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12
Q

What is the likely cause of a wound on a fold of skin?

A

friction, moisture

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13
Q

What is the likely cause of a wound on toes?

A

friction, decreased microcirculation

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14
Q

What is the likely cause of a wound on the bottom of the foot?

A

trauma, pressure

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15
Q

What is the likely cause of a wound on the shin or calf?

A

trauma, decreased circulation

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16
Q

What is the likely cause of a wound with round or elliptical edges?

A

pressure

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17
Q

What is the likely cause of a wound with jagged edges?

A

shear or friction

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18
Q

What is the likely cause of a wound with irregular shape?

A

vascular

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19
Q

What is the likely cause of a wound with a linear shape?

A

trauma or friction

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20
Q

What is the wound?

A

considered to be the open area only

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21
Q

What is the wound base?

A

the bottom of the wound (wound bed)

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22
Q

What is the wound depth?

A

vertical distance from the visible surface to the deepest area in the wound bed

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23
Q

What are the wound edges/margins?

A

inside perimeter of the wound (where epibole occurs)

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24
Q

What is the periwound area?

A

minimum of 4 cm surrounding the wound

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25
Q

What is a channel or pathway that extends in any direction from the wound through the subcutaneous tissue or muscle, creating dead space with the potential for abcess formation?

A

tunneling

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26
Q

What is tissue destruction underlying intact skin along the wound margins, the base of the wound is larger than the skin surface?

A

undermining

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27
Q

tunneling involves a ____ portion of the wound ege and undermining involves a ____ portion.

A

tunneling, undermining

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28
Q

What are tunneling and undermining caused by?

A

shearing forces on a wound

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29
Q

How is a wound measured via direct measurement?

A

measure the longest length and the widest width

30
Q

Wound surface area =

A

L x W x D in cm

31
Q

What are the cons of linear measurement?

A

cannot accurately determine depth if wound is covered with nonviable tissue, does not include consideration of periwound area

32
Q

How is wound tracing performed?

A

two-layered transparent film

33
Q

What are the advantages of wound tracing?

A

more accurate representation of wound size and shape, allows for future comparison

34
Q

What are some cons of wound tracing?

A

may be difficult to visualize wound perimeter through transparency

35
Q

What are some advantages of photographic measurement?

A

digital images are high quality, avoids contact with patient wound, provides periwound and wound bed characteristics, nice adjunct

36
Q

What are some cons of photographic measurement?

A

angle and focal distance can influence size, can be manipulated, lighting need specific wound care camera

37
Q

How is volumetric measurement done?

A

with dental, silicone molding, or saline filling

38
Q

What are the cons of volumetric measurement?

A

time consuming and painful, detrimental to wound healing

39
Q

When is total body surface area wound measurement performed?

A

large surface area wounds, burns

40
Q

What is another name for tunneling?

A

sinus tract

41
Q

Tunneling and undermining are common in which kinds of patients?

A

neuropathic ulcerations and surgical wounds

42
Q

What aspect of wound beds do you look at?

A

partial or full thickness, granulation tissue, nectrotic tissue, or other structures (fascia, muscle, tendon, bone, foreign bodies or debris)

43
Q

What is pink-red tissue with small buds?

A

granulation tissue

44
Q

What is purple tissue?

A

may indicate infection

45
Q

What is yellow, fibrous slimy green nonviable tissue?

A

slough

46
Q

What is black, no longer wet, dead tissue?

A

escar

47
Q

What aspects of wound edges do you look at?

A

distinctness, thickness, color, attachment to base, evidence of epithelialization, scarring, and pigment changes

48
Q

What aspects of wound drainage do you look at?

A

type, color, consistency, amount

49
Q

What does serous drainage indicate?

A

normal

50
Q

What does sanguinous drainage indicate?

A

normal acutely or in response to trauma

51
Q

What does serosansuinous drainage indicate?

A

normal

52
Q

What does purulent drainage indicate?

A

possible infection

53
Q

What seropurulent drainage indicate?

A

possible infection

54
Q

What does clear drainage indicate?

A

normal

55
Q

What does pale yellow drainage indicate?

A

normal

56
Q

What does red drainage indicate?

A

fresh blood

57
Q

What does dark brown drainage indicate?

A

dried blood

58
Q

What does blue-green drainage indicate?

A

possible pseudomonas infection

59
Q

What does thin, watery drainage indicate?

A

normal

60
Q

What does thick drainage indicate?

A

possible infection

61
Q

What does no drainage indicate?

A

dessicated wound bed

62
Q

What does minimal or moderate drainage indicate?

A

normal (within proportion)

63
Q

What does copious drainage indicate?

A

possible infection

64
Q

What periwound characteristics do you look for?

A

structure and quality, color, epithelial appendages, edema, temperature

65
Q

What is the classification of pitting edema?

A

1+ - 4 +

66
Q

What is 1+ edema?

A

barely perceptible depression

67
Q

What is 2+ edema?

A

easily identifiable depression, rebounds in

68
Q

What is 3+ edema?

A

depression rebounds in 15-30 secs 5-7 mm

69
Q

What is 4+ edema?

A

depression lasts > 30 secs > 7mm

70
Q

Where are the most common places to test for edema?

A

lateral malleolus, mid tibia

Integumentary (12 decks)

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