wound assessment Flashcards
wound etiology:
pressure
venous
arterial
neuropathic/diabetic ulcers
surgical dehiscence
skin tear
location often corresponds to wound etiology:
injuries are typically over a bony prominence
can occur anywhere, whenever sustained pressure on the skin in not relieved
arterial ulcers:
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
venous ulcers:
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
arterial and venous ulcers are often found in combination:
patient has venous insufficiency and arterial compromise
“mixed venous arterial”
neuropathic/diabetic ulcers:
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
wound location terms:
medial
lateral
anterior
posterior
a full wound assessment should be done on ____ basis
weekly
wound assessment parameters:
wound pain
wound size
wound bed
wound exudate
wound edge
wound odour
periwound skin
wound pain:
effects wound healing
uncontrolled wound pain can lead to hypoxia = impair wound healing and increase risk of infeciton
using pain scale:
before and after wound care
helps patient measure pain
0-10 numeric pain scale
wong-baker faces scales
conditions that cause pain:
adherent dressing
pressure
edema
inflammation
trauma
wound size:
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
measurements should be in ___ and recorded as:
cm
length X width X depth
wound length =
longest measurement regardless of direction
wound width =
widest measurement that is perpendicular (90 degrees) to the length
wound depth =
requires use of sterile measurement guide or probe
insert probe into deepest part of wound
wound depth: non-visible
“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
undermining =
destruction of tissue that occurs underneath intact skin of wound edge
sinus tract/tunnel =
channel that extends from any part of wound base and tracks into deeper tissue
wound progress =
steady decrease in measurements from week to week = indicator that wound is healing
expected rate of healing is ___ reduction in wound size in ___ weeks
20-40%
2-4
wound bed:
indicates whether the wound is improving or deteriorating
tissue type total must add up to 100%
eschar =
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
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
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
healthy tissue =
granulation tissue
superficial pink, red tissue
both are desired in a healing wound bed
granulation tissue =
firm, red, and moist pebbled healthy tissue
superficial pink, red tissue =
clean open pink or red wound bed with non-measurable depth
unhealthy tissue =
hypergranulation tissue
non-granulation tissue
friable
**not desirable in a wound bed
reasons for unhealthy tissue =
local or systemic infection
poor nutrition
poor circulation
pressure that is not offloaded
malignancy
excess/inadequate moisture
hypergranulation tissue =
raised above the level of the skin
referred to as proud flesh
non-granulation tissue =
moist red (pale to bright)
non-pebbled tissue
smooth look
friable wound =
unhealthy fragile red or pink tissue that bleeds easily
structures and foreign bodies =
bone
fascia
muscle
ligaments
tendons
hardware, sutures, mesh = delay healing
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
blister =
elevation or separation of epidermis containing fluid
no open wound =
suspected deep tissue injury has evidence of damage below the epidermis but skin remains intact
amount of exudate =
nill
scant or small
moderate
large or copious
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
wound exudate descriptors:
serous
sanguineous
serous/sanguineous
purulent
sanguineous/purulent
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
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
reasons for odour =
presence of necrotic tissue
wound drainage
dressing itself
wound edge =
critical in assessing progress of wound
2 characteristics
- attachment
wound edge: diffuse
edge is not well-defined
difficult to clearly see the wound outline
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
wound edge: epithelialized
pink to purple
shiny new epithelial tissue migrating over surface of wound
wound edge: non-attached
edge is not flush with wound bed
edge is like a cliff or undermining is present
wound edge: undermining
destruction of tissue that occurs underneath the intact skin of the wound edge
wound edge: rolled
rolled edge (epibole) is seen in cavity wounds when edge rolls inward (curls under)
wound edge: demarcated
edge is well-defined and easy to identify the outline of the wound
wound edge: callused
thickening of epidermis around open wound
hyperkeratosis
periwound:
skin around the wound
protecting it while containing enough moisture on wound bed to support moist wound healing = balancing act
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
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
induration:
abnormally firm periwound skin that is palpable
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
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
