WK6-Wound Examination Flashcards
What is the scoring for pitting edema ?
1+: barely perceptible depression, <2mm
2+: easily identifiable depression, rebounds <15 seconds, 2-4mm
3+: depression rebounds 15-30 seconds, 5-7mm
4+: depression last >30 seconds, >7mm
What technique is the most practical for noting the size of a wound ?
The Clock Technique
What is the difference between undermining and tunneling ?
Undermining is more like a cave where the wound bed is actually larger than what the wound edges let on
Tunneling is more like subway system with a destination, a narrow passageway within a wound bed
What are the different tissue types you can expect to find within a wound bed ?
Granulation, Necrotic, and other structures
If wound bed tissue is necrotic what should be noted in addition ?
should be described by color, consistency and percent of wound bed that tissue occupies.
Slough is yellow or tan in color and has a stringy mucous consistency, whereas fibrin is grabable, yellow, fibrous tissue. Lastly, Eschar is black necrotic tissue that can be either hard or soft.
Should be described as adherent or nonadherent. Adherence referring to the ease with which the necrotic tissue can be separated from the wound.
Describe the three different colors that may be present within a wound bed.
Red: ready to heal appearance with definite border; granulation tissue is present revascularization is apparent.
Yellow: pus, debris, fibrin, slough, and yellow exudate present which may require cleansing and minor debridement to promote healing; May require use of topical antimicrobial if wound is unusually contaminated
Black: necrotic tissue/eschar may be present; may include pus, fibrin, and other cellular components that inhibit granulation tissue
Identify and describe the different kinds of drainage that can come out of a wound.
Serous: normal, transudate, protein rich
Sanguinous: normal or acutely in response to trauma, consistency of blood or thick water, red or brown if dehydrated
Purulent: white to pale drainage, creamy consistency, indicates infection
Serosanguinous, and seropurulent are combinations of their names
Color, Consistency, and Amount should also be assessed.
When looking at the wound edges what characteristics should the therapist note ?
distinctness, attachment to base of wound, thickened/rolled, other changes
What are the signs of infection ?
erythema disproportionate to size of wound, poorly defined erythemal border, fever, warmth disproportionate to size of wound, could have induration
When doing a wound exam what are all the different things that should be assessed ?
Location, Size, Depth, Shape, Color, Drainage, Wound Edges, Periwound Characteristics, Odor, Pulses, Periwound Temperature, Signs of Infection.
