Week 3: Examination of Patients with Open Wounds Flashcards
What are some things that should be assessed during a cardiovascular/pulmonary systems review?
heart rate, blood pressure, respiratory rate, edema, pulse oximetry
What are some things that should be assessed during a musculoskeletal systems review?
structure, posture, ROM, strength
What are some things that should be assessed during a neuromuscular systems review?
balance, gait, mobility, transfers
What are some things that should be assessed during a gastrointestinal systems review?
nutrition intake, supplementation, continence, BMI
What are some nutritional assessment screening tools?
Rapid Eating and Activity Assessment for Patients (REAP)
Weight, Activity, Variety, Excess (WAVE)
What are some things that should be assessed during a urogenital systems review?
incontinence, poorly controlled diabetes, UTIs
______ is one of the leading causes of skin breakdown?
Incontinence
What are some things that should be assessed during an integumentary systems review?
skin integrity, skin color, scar formation, hair and nail growth
What is the ability of skin to return to its original shape/condition?
turgor
What are some routine integumentary tests and measures?
integumentary integrity, circulation (capillary refill), and sensory integrity (monofiliament)
What is the likely cause of a wound on a bony prominence?
pressure
What is the likely cause of a wound on a fold of skin?
friction, moisture
What is the likely cause of a wound on toes?
friction, decreased microcirculation
What is the likely cause of a wound on the bottom of the foot?
trauma, pressure
What is the likely cause of a wound on the shin or calf?
trauma, decreased circulation
What is the likely cause of a wound with round or elliptical edges?
pressure
What is the likely cause of a wound with jagged edges?
shear or friction
What is the likely cause of a wound with irregular shape?
vascular
What is the likely cause of a wound with a linear shape?
trauma or friction
What is the wound?
considered to be the open area only
What is the wound base?
the bottom of the wound (wound bed)
What is the wound depth?
vertical distance from the visible surface to the deepest area in the wound bed
What are the wound edges/margins?
inside perimeter of the wound (where epibole occurs)
What is the periwound area?
minimum of 4 cm surrounding the wound
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?
tunneling
What is tissue destruction underlying intact skin along the wound margins, the base of the wound is larger than the skin surface?
undermining
tunneling involves a ____ portion of the wound ege and undermining involves a ____ portion.
tunneling, undermining
What are tunneling and undermining caused by?
shearing forces on a wound
How is a wound measured via direct measurement?
measure the longest length and the widest width
Wound surface area =
L x W x D in cm
What are the cons of linear measurement?
cannot accurately determine depth if wound is covered with nonviable tissue, does not include consideration of periwound area
How is wound tracing performed?
two-layered transparent film
What are the advantages of wound tracing?
more accurate representation of wound size and shape, allows for future comparison
What are some cons of wound tracing?
may be difficult to visualize wound perimeter through transparency
What are some advantages of photographic measurement?
digital images are high quality, avoids contact with patient wound, provides periwound and wound bed characteristics, nice adjunct
What are some cons of photographic measurement?
angle and focal distance can influence size, can be manipulated, lighting need specific wound care camera
How is volumetric measurement done?
with dental, silicone molding, or saline filling
What are the cons of volumetric measurement?
time consuming and painful, detrimental to wound healing
When is total body surface area wound measurement performed?
large surface area wounds, burns
What is another name for tunneling?
sinus tract
Tunneling and undermining are common in which kinds of patients?
neuropathic ulcerations and surgical wounds
What aspect of wound beds do you look at?
partial or full thickness, granulation tissue, nectrotic tissue, or other structures (fascia, muscle, tendon, bone, foreign bodies or debris)
What is pink-red tissue with small buds?
granulation tissue
What is purple tissue?
may indicate infection
What is yellow, fibrous slimy green nonviable tissue?
slough
What is black, no longer wet, dead tissue?
escar
What aspects of wound edges do you look at?
distinctness, thickness, color, attachment to base, evidence of epithelialization, scarring, and pigment changes
What aspects of wound drainage do you look at?
type, color, consistency, amount
What does serous drainage indicate?
normal
What does sanguinous drainage indicate?
normal acutely or in response to trauma
What does serosansuinous drainage indicate?
normal
What does purulent drainage indicate?
possible infection
What seropurulent drainage indicate?
possible infection
What does clear drainage indicate?
normal
What does pale yellow drainage indicate?
normal
What does red drainage indicate?
fresh blood
What does dark brown drainage indicate?
dried blood
What does blue-green drainage indicate?
possible pseudomonas infection
What does thin, watery drainage indicate?
normal
What does thick drainage indicate?
possible infection
What does no drainage indicate?
dessicated wound bed
What does minimal or moderate drainage indicate?
normal (within proportion)
What does copious drainage indicate?
possible infection
What periwound characteristics do you look for?
structure and quality, color, epithelial appendages, edema, temperature
What is the classification of pitting edema?
1+ - 4 +
What is 1+ edema?
barely perceptible depression
What is 2+ edema?
easily identifiable depression, rebounds in
What is 3+ edema?
depression rebounds in 15-30 secs 5-7 mm
What is 4+ edema?
depression lasts > 30 secs > 7mm
Where are the most common places to test for edema?
lateral malleolus, mid tibia
