Week 6 Wound Exams and Assessments Flashcards
Objective Examination
Shape
Size
Wound Bed Color
Undermining/Tunneling
Drainage
Wound Edges
Periwound and Extrinsic Tissue
Temperature
Edema
Temperature
Odor
Signs of Infection
Signs of Healing
Special Tests
Location
- Left/Right
- Medial/ Lateral
_ anatomical terminology - May be in relation to a bony landmark
Shape
Circular
round
Oval
Irregular
wound Size Techniques
- Photograph with a ruler
- Wound tracings
- Direct measurement
- Longest, Widest, Deepest
- Clock Method
- Total Body Surface area
- Volume (water displacement)
Undermining
- Erosion of tissue close to the wound edges
- Results in a large wound with small opening
Tunneling
Narrow passageway within a wound bed
Sinus tract
Elongated cavity or abscess that drains to the body surface
Fistula
Tunnel that connects with a body cavity or organ
Wound bed Tissue Types
- Granulation
- Necrotic : adherent or non adherent
- Describe in terms of percentages
- Treat the most severe color first
Red Color Descriptor
Red: ready to heal appearance with definite borders; granulation tissue is present and revascularization is apparent
Yellow Color Descriptor
Pus, debris, fibrin, slough, and yellow exudate present which may require cleansing and minor debridement to promote healing.
- May require use of a topical antimicrobial if wound is unusually contaminated
Black Color Descriptor
Necrotic tissue/eschar may be present; may include pus, fibrin and other cellular components that inhibit granulation tissue
Yellow Slough
-Produced by autolysis
-Soft/mushy
- Product of inflammatory stage
- Snot like consistency
- Yellow or white
- Cant grab it
autolysis= the destruction of cells or tissues by their own enzymes, especially those released by lysosomes.)
Yellow Fibrin
- Yellow but more fibrous in appearance
- Can be mistaken as connective tissue
- Yellow and white
- You can grab it
Serous drainage
Looks brown on the dressing
- yellow
Sanguineous drainage
- bloody
Serosanguinous
Yellow that is blood tinged
Purulent Drainage
Milky/thiccc puss like drainage
Seropurulent
Yellow Thiccc drainage
Color: Clear
Normal
Color: Pale Yellow
normal
Color: Red
blood
Color: dark brown
dried blood
Color: blue-green
Probable pseudomonas infection
If the consistency of the drainage is thick this means?
Possible infection
If a wound edge has distinctness it means
it can occur in deeper wounds that are more defined edges and margins
Indistinct wound edges mean
It is not clearly defined edges
Attachment to base of wound means
Attached wounds tend to heal quicker
Thickened/Rolled edges
Epiboly
Hyperkeratotic (callus)
- Epiboly is a rolled edge in a crater type wound, keratinocytes migrate down instead of across which they then think they are finished healing the wound; they only made the edges thicker and left the wound open/stagnant/unhealed
Pitting Edema Scale
1+ = Barley perceptible depression : <2mm
2+ = Easily identifiable depression, rebounds <15 seconds : 2-4mm
3+ = depression rebounds 15-30 seconds : 5-7mm
4+ = depression lasts >30 seconds : >7mm
Odor
waft
Sickly sweet= pseudomonas
Ammonia like = proteus infection
Musky= typical of malignant tissue
Signs of Infection
- Erythema disproportionate to size of the wound
- Poorly defined erythema boarder
- Fever
- Warmth disproportionate to size of the wound
- Could have induration
Induration= when the soft tissue of different parts of the body, especially the skin, becomes thicker and harder due to an inflammatory process caused by various triggering factors.
What can PTA’s not do?
” There are certain interventions which require immediate and continuous examination and evaluation throughout the intervention and are thus beyond the scope of a PTA
Role of a PTA in wound care
- Allowed to follow Plan of Care and treatment
- Can conduct objective tests to measure goals
-Can measure wounds - describe wounds; color, drainage, odor, wound bed, periwound, ect
- Circumferential measurements
NPUAP : National Pressure Ulcer Advisory Panel Scale
Stage 1= only epidermal damage can be noted visibly, although tissue biopsies may show tissue damage extending below epidermis : Non-blanchable erythema of intact skin; area may be painful, warmer, cooler, firmer and softer compared to adjacent area
Stage 2= partial thickness ulcer involving the epidermis, dermis, or both; NO ADIPOSE OR DEEPER TISSUES ARE VISBLE
Stage 3= Full thickness skin loss involving the epidermis, dermis, and subcutaneous tissue. ( BONE, TENDON, LIGAMENTS, MUSCLE ARE NOT VISBLE OR PALABLE)
Stage 4= Full thickness skin loss involving the epidermis, dermis, subcutaneous tissue, fascia and underlying structures such as MUSCLE, TENDON, JOINT CAPSULE, LIGAMENT, CARTLIAGE OR BONE ARE VISBLE (CORE 4)
Unstageable= Full thickness; once devitalized tissue is removed the wound will be a stage 3 or 4
Braden scale
This test is used for predicating Ulcer development
<18 = at risk
15-18 = mild risk
13-14= moderate risk
<13 high risk
Look up chart to understand how it is counted
Wagner Scale
Used for Neuropathic Ulcers
Grade 0= No open lesion; may have deformity or cellulitis; Superficial or partial thickness
Grade 1= Superficial ulcer; partial or full thickness
Grade 2= Deep ulcer to tendon, capsule, or bone; Full thickness
Grade 3= Deep ulcer with abscess, osteomyelitis or joint sepsis; full thickness
Grade 4= Localized gangrene; full thickness
Grade 5= gangrene of the entire foot; Full thickness
Monofilament
4.17= Decreased sensation; produced 1g of pressure
5.07= loss of protective sensation; produced 10g of pressure
6.10= Absent sensation; produced 75g of pressure
Arterial Wound Characteristics
- Position: primarily LE, distal toes, dorsum of the foot, areas of trauma
- Little to no drainage
- Periwound/Extrinsic Tissue: thin, shiny, anhydrous skin, loss of hair, thickened yellow nails, pale dusky or cyanotic skin, edema is unusual
-Temperature; Cool or decreased
- Pulse; Decreased or absent pedal pulse
- Wound characteristics; Begin, small/shallow, round and regular shaped to conform to trauma, any granulation tissue will be pale/grey, necrotic tissue desiccated with black eschar
- This is from a lack of blood flow to to LE, trauma, acute embolism, diabetes mellitus, RA, Arteriosclerosis, atherosclerosis
Venous Wounds
Commonly caused by venous hypertension causing the calf pump to fail, vein dysfunction, bicuspid valves fail to close
-Position= Medial leg, medial malleolus, areas of trauma
-Presentation= irregular shaped, fibrous, glossy coating, red, ruddy wound bed, copious amounts of drainage
-Periwound/Extrinsic tissue= edema, dermatitis/cellulitis, hemosiderin staining, lipodermatosclerosis
- Temperature= Normal to mild warm
Pressure Wound
- Localized area of necrosis that develops when compressed between firm surfaces like a paraplegic sitting in a chair for hours a day without moving can cause him to get pressure injuries on their ischial tuberosities
-Position= over bony prominences, areas of outside pressure
- Presentation= description from NPUAP
Periwound/Extrinsic Tissue= Surrounded by a ring of erythema, localized warmth, fibrous and induration, dermatitis common,
-Temperature= increased in areas of hyperemia, decreased in areas of necrosis(necrotic)
- Wound characteristics= typically range from non-blanchable erythema of intact skin to full thickness destruction
–> deeper ulcers have exposed tendon, muscle, capsule and or bone
–>tunneling, undermining common
–> unless previously debrided a necrotic base is normal
Neuropathic Wounds
Can happen from diabetes, vascular diseases
-Position= plantar aspect of the foot, midfoot with charco foot deformity, forefoot under calluses, heel friction areas, dorsal/or tips of toes if clawed, medial 1st and lateral 5th MTPJ
- Presentation= Rounded, punched out, callused rim, minimal drainage unless infected, eshcar or necrotic base uncommon
- Periwound/extrinsic Tissue= Dry, cracked skin, callus, foot structural deformities
- Temperature= normal or increased
- Pulse= normal or accentuated (people with diabetes may have an abnormal ABI/bounding pulse)
