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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
Q

slough =

A

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
Q

autolytic debridement =

A

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
Q

healthy tissue =

A

granulation tissue

superficial pink, red tissue

both are desired in a healing wound bed

28
Q

granulation tissue =

A

firm, red, and moist pebbled healthy tissue

29
Q

superficial pink, red tissue =

A

clean open pink or red wound bed with non-measurable depth

30
Q

unhealthy tissue =

A

hypergranulation tissue

non-granulation tissue

friable

**not desirable in a wound bed

31
Q

reasons for unhealthy tissue =

A

local or systemic infection
poor nutrition
poor circulation
pressure that is not offloaded
malignancy
excess/inadequate moisture

32
Q

hypergranulation tissue =

A

raised above the level of the skin

referred to as proud flesh

33
Q

non-granulation tissue =

A

moist red (pale to bright)

non-pebbled tissue

smooth look

34
Q

friable wound =

A

unhealthy fragile red or pink tissue that bleeds easily

35
Q

structures and foreign bodies =

A

bone
fascia
muscle
ligaments
tendons

hardware, sutures, mesh = delay healing

36
Q

non-visible wound bed =

A

part of all of the wound bed cannot be seen by the naked eye due to tunnel, sinus track, or undermined area

37
Q

blister =

A

elevation or separation of epidermis containing fluid

38
Q

no open wound =

A

suspected deep tissue injury has evidence of damage below the epidermis but skin remains intact

39
Q

amount of exudate =

A

nill
scant or small
moderate
large or copious

39
Q

wound exudate character =

A

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
Q

wound exudate descriptors:

A

serous
sanguineous
serous/sanguineous
purulent
sanguineous/purulent

40
Q

small or large amount?

A

look at amount of exudate on dressing along = NOT helpful

must assess amount of drainage in relation to size of wound

40
Q

wound odour =

A

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
Q

reasons for odour =

A

presence of necrotic tissue
wound drainage
dressing itself

41
Q

wound edge =

A

critical in assessing progress of wound

2 characteristics
- attachment

42
Q
A
43
Q

wound edge: diffuse

A

edge is not well-defined

difficult to clearly see the wound outline

43
Q

wound edge: attached

A

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
Q

wound edge: epithelialized

A

pink to purple

shiny new epithelial tissue migrating over surface of wound

45
Q
A
46
Q

wound edge: non-attached

A

edge is not flush with wound bed

edge is like a cliff or undermining is present

47
Q

wound edge: undermining

A

destruction of tissue that occurs underneath the intact skin of the wound edge

48
Q

wound edge: rolled

A

rolled edge (epibole) is seen in cavity wounds when edge rolls inward (curls under)

49
Q

wound edge: demarcated

A

edge is well-defined and easy to identify the outline of the wound

50
Q

wound edge: callused

A

thickening of epidermis around open wound

hyperkeratosis

51
Q

periwound:

A

skin around the wound

protecting it while containing enough moisture on wound bed to support moist wound healing = balancing act

52
Q

macerated periwound:

A

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
Q

eythema:

A

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
Q

induration:

A

abnormally firm periwound skin that is palpable

55
Q

erythema and induration =

A

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
Q

rash to periwound skin:

A

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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