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Integ Midterm > wound assessment > Flashcards

wound assessment Flashcards

1
Q

wound etiology:

A

pressure
venous
arterial
neuropathic/diabetic ulcers
surgical dehiscence
skin tear

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2
Q

location often corresponds to wound etiology:

A

injuries are typically over a bony prominence

can occur anywhere, whenever sustained pressure on the skin in not relieved

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3
Q

arterial ulcers:

A

result of tissue ischemia

commonly found on lower legs and toes

lesions are painful

risk for infection due to restricted amount of oxygenated blood supplying the tissues

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4
Q

venous ulcers:

A

usually on lower leg or ankle

caused by impaired return of venous blood to the heart

valves of the vein are impaired or damaged = causing edema

failure of calf muscle to contract further impairs the ability to push venous blood back to the heart

can result in skin and tissue changes leading to ulceration

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5
Q

arterial and venous ulcers are often found in combination:

A

patient has venous insufficiency and arterial compromise

“mixed venous arterial”

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6
Q

neuropathic/diabetic ulcers:

A

primarily caused by peripheral neuropathy, structural foot changes, and trauma/pressure

patient cannot feel when trauma or pressure is occurring to the tissue = ulceration

commonly found on plantar surface of foot or areas of foot exposed to repetitive trauma

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7
Q

wound location terms:

A

medial
lateral
anterior
posterior

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8
Q

a full wound assessment should be done on ____ basis

A

weekly

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9
Q

wound assessment parameters:

A

wound pain
wound size
wound bed
wound exudate
wound edge
wound odour
periwound skin

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10
Q

wound pain:

A

effects wound healing

uncontrolled wound pain can lead to hypoxia = impair wound healing and increase risk of infeciton

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11
Q

using pain scale:

A

before and after wound care

helps patient measure pain

0-10 numeric pain scale
wong-baker faces scales

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12
Q

conditions that cause pain:

A

adherent dressing
pressure
edema
inflammation
trauma

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13
Q

wound size:

A

assesses size of wound

measures healing or deterioration of wound

wounds that are healing should decrease in size consistently over time

objective means of monitoring progress

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14
Q

measurements should be in ___ and recorded as:

A

cm

length X width X depth

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15
Q

wound length =

A

longest measurement regardless of direction

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16
Q

wound width =

A

widest measurement that is perpendicular (90 degrees) to the length

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17
Q

wound depth =

A

requires use of sterile measurement guide or probe

insert probe into deepest part of wound

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18
Q

wound depth: non-visible

A

“true” size indicates area of undermining or sinus tracts

measurements made with imaginary clock

12 o’clock position = head
6 o’clock position = feet

probe gently at 12 o’clock position and swab gently until resistance is felt

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19
Q

undermining =

A

destruction of tissue that occurs underneath intact skin of wound edge

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20
Q

sinus tract/tunnel =

A

channel that extends from any part of wound base and tracks into deeper tissue

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21
Q

wound progress =

A

steady decrease in measurements from week to week = indicator that wound is healing

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22
Q

expected rate of healing is ___ reduction in wound size in ___ weeks

A

20-40%

2-4

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23
Q

wound bed:

A

indicates whether the wound is improving or deteriorating

tissue type total must add up to 100%

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24
Q

eschar =

A

dry

black or brown dead tissue

dead (necrotic) type of tissue = indicates wound is in inflammatory phase of healing

turns to slough once body begins process of autolytic debridement

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25
slough =
dry or wet loose or firmly attached yellow or brown dead tissue dead (necrotic) type of tissue = indicates wound is in inflammatory phase of healing
26
autolytic debridement =
moisture added to the wound facilitates this process natural process that breaks down damaged tissue at a wound site using the body's own enzymes and moisture endogenous phagocytic cells and proteolytic enzymes break down necrotic tissue
27
healthy tissue =
granulation tissue superficial pink, red tissue both are desired in a healing wound bed
28
granulation tissue =
firm, red, and moist pebbled healthy tissue
29
superficial pink, red tissue =
clean open pink or red wound bed with non-measurable depth
30
unhealthy tissue =
hypergranulation tissue non-granulation tissue friable **not desirable in a wound bed
31
reasons for unhealthy tissue =
local or systemic infection poor nutrition poor circulation pressure that is not offloaded malignancy excess/inadequate moisture
32
hypergranulation tissue =
raised above the level of the skin referred to as proud flesh
33
non-granulation tissue =
moist red (pale to bright) non-pebbled tissue smooth look
34
friable wound =
unhealthy fragile red or pink tissue that bleeds easily
35
structures and foreign bodies =
bone fascia muscle ligaments tendons hardware, sutures, mesh = delay healing
36
non-visible wound bed =
part of all of the wound bed cannot be seen by the naked eye due to tunnel, sinus track, or undermined area
37
blister =
elevation or separation of epidermis containing fluid
38
no open wound =
suspected deep tissue injury has evidence of damage below the epidermis but skin remains intact
39
amount of exudate =
nill scant or small moderate large or copious
39
wound exudate character =
drainage consists of dead cells and liquefied necrotic tissue type and appearance largely dependent on level of moisture, microorganisms presents, type and amount of necrotic tissue in the wound
39
wound exudate descriptors:
serous sanguineous serous/sanguineous purulent sanguineous/purulent
40
small or large amount?
look at amount of exudate on dressing along = NOT helpful must assess amount of drainage in relation to size of wound
40
wound odour =
unpleasant smell after cleaning social and physiological effects malodourous wound have on QOL one sign of infection caused from high bacterial count can only be assessed after old dressing has been removed and wound has been cleaned
41
reasons for odour =
presence of necrotic tissue wound drainage dressing itself
41
wound edge =
critical in assessing progress of wound 2 characteristics - attachment
42
43
wound edge: diffuse
edge is not well-defined difficult to clearly see the wound outline
43
wound edge: attached
edge appears flush with wound bed or has a sloping edge facilitates epithelial cells to migrate over wound surface to close the wound ex) diffuse and epithelialized
44
wound edge: epithelialized
pink to purple shiny new epithelial tissue migrating over surface of wound
45
46
wound edge: non-attached
edge is not flush with wound bed edge is like a cliff or undermining is present
47
wound edge: undermining
destruction of tissue that occurs underneath the intact skin of the wound edge
48
wound edge: rolled
rolled edge (epibole) is seen in cavity wounds when edge rolls inward (curls under)
49
wound edge: demarcated
edge is well-defined and easy to identify the outline of the wound
50
wound edge: callused
thickening of epidermis around open wound hyperkeratosis
51
periwound:
skin around the wound protecting it while containing enough moisture on wound bed to support moist wound healing = balancing act
52
macerated periwound:
too much moisture in contact with surrounding tissue appears over-hydrated and white in colour increases susceptibility to damage and improved moisture control is needed
53
eythema:
redness of skin range from intense bright red to dark red in colour combo with warmth or increased pain = indication of infection = further medical intervention
54
induration:
abnormally firm periwound skin that is palpable
55
erythema and induration =
depending on timing, it may be part of normal inflammatory process after initial injury evaluate whether it is contained or extends beyond 2cm from wound edge
56
rash to periwound skin:
may have several causes - frequent washing with soap or other irritants temporary eruption to skin can be raised, red, and itchy bacterial, fungal, or inflammatory

Integ Midterm (9 decks)

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