Wound Assessment Flashcards
wound etiologies
surgical/trauma
arterial, venous, mixed insufficiency
pressure injury
neuropathic
skin tear
atypical
steps to wound assessment
etiology
anatomical location
onset/age/progression of wound
grading/categorization
exudate
methods of wound size assessment
perpendicular
clock method
area calculation
tracing
how is the perpendicular method of wound size assessment completed
length and width measurement
sinus tunneling vs tract vs fistula
tunneling - wound to wound
tract - along fascia to another wound
fistula - wound to organ
serous exudate
clear fluid
typically harmless unless with lymphedema
serosanguinous fluid
water mix/serous fluid with sanguineous fluid
light red coloring and slightly thicker than serous fluid
purulent fluid
green
infection
panfil turns ____ when exposed to _____
green
exudate
fibrinous fluid description/indication
cloudy, thin and watery
normal - fibrin strands are present
seropurulent fluid description/significance
yellow, thicker fluid
bacterial infection / necrotic liquid tissue
what is exudate graded on
color, amount of it, smell
what is important when observing slough
it is the same color as tendon, look for striations to ensure the difference
indications of local infection
redness
swelling
pain
increased exudate
indications of systemic sepsis
fever, general malaise, feeling poor
induration
swelling in the surrounding skin
- build up of tissue can indicate a wound infection starting
hemosiderin staining
indicative of a venous issue
- dark red/purple looking staining
maceration
soggy skin surrounding a wound
attached margins indicate
healthy healing
not attached wound margins indicate
skin is not attached to base layer and anything below it is dead
what is the word for rolled wound edges
epiboly
what is done to epiboly
scoring of the edges of the wound to initiate acute phases of recovery
