Wound Flashcards
Questions to ask
when/how did wound begin precipitating even associated? treatment used? nutrition? alcohol/tobacco/drug hits? physical acitivt? shoes? assistive devices?
Wound descriptions
dimensions subcutaneous extensions tissue type drainage periwound skin color edema edge description odor pain sensation (pressure, vib, light touch, temp, proprio) pulses
Dimension
perpendicular, clockwise, photograph
perpendic: longest and perpendic line for width; cuetip for depth
clock: sacral wounds- 6 caudal/inferior, 12 sephalic/superior
Subcutaneous extension
Undermining: deduction of connective tissue between dermis and subcutaneous tissue
Sinus: long, narrow opening along fascial plane (cuetip until spongy end feel)
Tunneling: tract that connects two wounds
Tissue type info
indicates healing phase
provides data for measureing outcomes
helps determine optimal treatment plan, primary/secondary dressings
may help indicate other diseases
Tissue: ESCHAR
dead tissue
black, brown, yellow, or gray fibrin
may be hard and dry or soft and rubbery
may be dry gangrene or wet gangrene
Tissue: YELLOW SLOUGH
dead tissue byproduct of autolysis
softer, lighter necrotic debris byproduct of autolysis beneath eschar common in inflammatory phase of healing soft and mushy, hard to grasp w/ forceps
Tissue: GRANULATION TISSUE
red, beefy looking result of angiogenesis new capillaries and extracellular matrix anemic to bright red necessary for closure by secondary intention for STSGs carefully protected becomes scar
Tissue: DEVITALIZED FASCIA
dull in appearance
composed of fibrous connective tissue
around or between other tissues
Tissue: MUSCLE
striated reddish when healthy brownish-gray when devitalized sensate when healthy PAINFUL when exposed
Tissue: TENDONS
shiny and stringy when healthy
convered in fibrous sheath w/ synovial fluid/ fatty fluid (paratenon- provides nutrients for healing)
Tissue: BONE
tan color
hard palpation w/metal instrument
covered w/ periosteum when healthy
dark brown when necrotic- has to be debrided
Tissue: ADIPOSE
shiny, yellow globules when healthy
shriveled and dry when devitalized
poor vasular
frequent source of abscess formation
Drainage types
SEROUS: clear watery
SANGUINEOUS: red blood
SEROSANGUINEOUS: serous with pink tinge
EXUDATE: pale yellow drainage, dead CELLS, serum, lysed debris, high protein content
TRANSUDATE: pale drainage w/ low protein content
SEROPURULENCE: slightly thicker yellow drainage indicative in colonized BACTERIA
PURULENC: thick necrotic drainage
LYMPH: water and dissolved proteins (mostly albumin) too large to be absorbed by capillaries (like egg whites)
Skin color: ERYTHEMA
abnormal red color
indicate underlying infection
Indicative of stage 1 pressure ulcer if over bony prominence
may be superficial or partial thickness burn
Skin color: CYANOSIS
dusky or bluish color
lack of oxy to tissue
present in both arterial or venous wounds
Skin color: DEEP TISSUE INJURY
repeated shear forces on insensate area
any area
result from medicatin ex: cougmadin
Skin color: HEMOSIDERIN
brownish-purple color
gaiter area of leg
from extravasation of red blood cells into interstitial tissue
cell is lysed and hemoglobin released into tissue
distally and migrates proximally
chronic venous insuffiency!
Skin color: ECCHYMOSIS
subdermal hemorrage
result of acute injur
look for delerium- cognitive response to trauma
Edges: EVEN
arterial wounds- not enough O2
causes punctate appearance
Edges: IRREGULAR
venous wounds
occur as wound epithelializes
Edges: CLOSED/ROLLING
sign of halted healing process
cells are SENESCENT- unable to reproduce
rolled edge is EPIBOLE
Edges: HYPERKERATOSIS
overdelopment of outerlayer
appear as thickened skin on edge of wound like callus
from friction
Edges: EPITHELIALIZATION
migration of epithelial cells over granulation tissue
include % of edges that are epithelializating
Odor types
Pseudomonas: sweet, greenish draining
Putrid: indicates infection
Necrotic: accompanies extensive necrotic tissue
Musky: typical of malignant cancer tissue
Pain types
Deep pain: cramping, indicative of ISCHEMIA/HYPOXIA, comfortable in dependent position
Throbbing, localized pain: indicative of infection; deep pain increases w/ pressure indicative of osteomyelitis
Superficial tenderness: exposed nerve endings accomponied by sharp shooting pains
Pain w/ stim of red tissue: living muscle
Sensation types
Pressure: use Semmes-Weinstein monofilaments
Vibration: 128 H tuning fork
Light touch: soft object to brush skin
Temp: any warm/cool objects (prob if 3-4 degrees diff than other)
Proprioception: start distally and work proximally
