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
