wound assessment Flashcards
Patient assessment for wound care
- Wound drainage (amount, color), odor (when do you encounter it? Entering the room, removing dressing, etc), exposed structures (bones/tendons/muscles), previous amputation
- Periwound skin- erythemia, edema, hemosiderin deposition, indurated, macerated, dry, scaly, absence of hair
- Wound border (shape), temperature of wound
- Sensation, pain profile, assistive devices, support surfaces, Barden Scale
What is Barden scale score?
- Assess pt’s rick for development of pressure ulcers
- Base on: sensory perception, moisture, activity, mobility, nutrition, friction/shear
- Scale 6-23; lower score= dec level of functioning & inc risk for ulcer development
- < 12 high risk (90-100% of stage II or deeper)
- Look at slide 14
What are the 5 aspects of wound assessment?
- Location
- Appearance (color):
- Measurement
- Classification
- pain
All about Appearance of wound assessment- color and wound bed
- (color): Red (healthy; BF), Pink (poor BF), purple (engorged (edema, trauma)), black = necrotic, yellow= slough, gray = nonviable, green = infection, white = ischemia.
- Wound bed: granulation tissue (what % if present), necrotic tissue (color, consistency- Eschar (black), Slough (yellow)
Measurement during wound assessment
- Measure in cm, length =vertically, width= horizontally, depth
- Clock: 12 = pts head, 6= pts feet, 3 & 9 =width
- Depth- use cue-tip, insert into deepest visible portion
- Undermining- area of tissue under the wound edges that becomes eroded resulting in a large wound with small opening
- Tunneling (sinus Tract)- narrow passageway w/in wound bed
What is used to Classify a wound?
- NPUAP- National pressure ulcer advisory panel
- Wagner ulcer grade: Describes by depth and soft tissue involvement
Describe a suspected Deep Tissue injury
- Purple/maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue
- Compared to adjacent tissue it may be painful, firm, mushy, warmer or cooler
What is a stage 1 Ulcer ?
- Intact skin with non blanchable redness of a localized area
- Usually over bony prominence
- Darkly pigmented skin may not have visible blanching; color may be different from surrounding area
Describe to me a stage II ulcer
- Partial thickness loss of dermis; presents as shallow open ulcer with red/pink wound bed
- Can also present as intact or open/ruptured serum filled blister
Ta ta ta tell me about a stage III ulcer
- Full thickness tissue loss
- May see fat, but no bone/tendon/muscle.
- Slough MAY be present but does not obscure the depth of tissue loss.
- May include undermining and tunneling
Stage 4 ulcer
- Full thickness tissue loss
- Exposed bone/tendon/muscle
- Slough/eschar may be present on some parts of wound bed
- Often include undermining/tunneling
Unstageable
Full thickness tissue loss in which base of ulcer is covered by slough/eschar in the wound bed
The Wagner Ulcer Grade
0- no ulcer in a high risk foot
1-superficial ulcer involving full skin thickness but not underlying tissue
2- deep ulcer, penetrating down to ligaments and muscle, but no bone involvement
3- deep ulcer with cellulitis or abscess formation, often with osteomyelitis
4- localized gangrene
5-Extensive gangrene involving the whole foot
Pain associated with wound care
- Wound covering, adjusting support surface, repositioning the patient, referring for appropriate medications
- May indicate infection, underlying tissue destruction, vascular insufficiency
- Absence may indicate nerve destruction, neuropathy
- Use pain scale (VAS, Faces), if unable to verbally response look for facial grimacing, retraction of limb, tense
The components of a Vascular assessment
-Vascular history, physical exam (peripheral pulses, ABI, sensation-light tough/mono-filament), angiography (MD)
