Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Fall 2023 Integumentary > Week 6 Wound Exams and Assessments > Flashcards

Week 6 Wound Exams and Assessments Flashcards

1
Q

Objective Examination

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Location

A
  • Left/Right
  • Medial/ Lateral
    _ anatomical terminology
  • May be in relation to a bony landmark
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Shape

A

Circular
round
Oval
Irregular

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

wound Size Techniques

A
  • Photograph with a ruler
  • Wound tracings
  • Direct measurement
  • Longest, Widest, Deepest
  • Clock Method
  • Total Body Surface area
  • Volume (water displacement)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Undermining

A
  • Erosion of tissue close to the wound edges
  • Results in a large wound with small opening
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Tunneling

A

Narrow passageway within a wound bed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Sinus tract

A

Elongated cavity or abscess that drains to the body surface

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Fistula

A

Tunnel that connects with a body cavity or organ

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Wound bed Tissue Types

A
  • Granulation
  • Necrotic : adherent or non adherent
  • Describe in terms of percentages
  • Treat the most severe color first
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Red Color Descriptor

A

Red: ready to heal appearance with definite borders; granulation tissue is present and revascularization is apparent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Yellow Color Descriptor

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Black Color Descriptor

A

Necrotic tissue/eschar may be present; may include pus, fibrin and other cellular components that inhibit granulation tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Yellow Slough

A

-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.)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Yellow Fibrin

A
  • Yellow but more fibrous in appearance
  • Can be mistaken as connective tissue
  • Yellow and white
  • You can grab it
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Serous drainage

A

Looks brown on the dressing
- yellow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Sanguineous drainage

A
  • bloody
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Serosanguinous

A

Yellow that is blood tinged

18
Q

Purulent Drainage

A

Milky/thiccc puss like drainage

19
Q

Seropurulent

A

Yellow Thiccc drainage

20
Q

Color: Clear

A

Normal

21
Q

Color: Pale Yellow

A

normal

22
Q

Color: Red

A

blood

23
Q

Color: dark brown

A

dried blood

24
Q

Color: blue-green

A

Probable pseudomonas infection

25
Q

If the consistency of the drainage is thick this means?

A

Possible infection

26
Q

If a wound edge has distinctness it means

A

it can occur in deeper wounds that are more defined edges and margins

27
Q

Indistinct wound edges mean

A

It is not clearly defined edges

28
Q

Attachment to base of wound means

A

Attached wounds tend to heal quicker

29
Q

Thickened/Rolled edges

A

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

30
Q

Pitting Edema Scale

A

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

31
Q

Odor

A

waft
Sickly sweet= pseudomonas
Ammonia like = proteus infection
Musky= typical of malignant tissue

32
Q

Signs of Infection

A
  • 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.

33
Q

What can PTA’s not do?

A

” There are certain interventions which require immediate and continuous examination and evaluation throughout the intervention and are thus beyond the scope of a PTA

34
Q

Role of a PTA in wound care

A
  • 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
35
Q

NPUAP : National Pressure Ulcer Advisory Panel Scale

A

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

36
Q

Braden scale

A

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

37
Q

Wagner Scale

A

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

38
Q

Monofilament

A

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

39
Q

Arterial Wound Characteristics

A
  • 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
40
Q

Venous Wounds

A

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
41
Q

Pressure Wound

A
  • 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
42
Q

Neuropathic Wounds

A

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)

Fall 2023 Integumentary (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions