Wound assessment Flashcards
What are the three areas/aspects to examine when examining the wound?
- Periwound
- Wound tissue
- Wound exudate
What should you observe for the periwound?
- Texture
- Scar Tissue
- Callus
- Maceration
- Edema
- Color
- Temperature
- Hair distribution
- Nails
- Blisters
- Sensation (pain, thermal, touch)
What makes aging skin weak?
The fact that it is dry due to atrophy of the fatty tissue and epithelial layers in the dermis. Loss of collagen. Epidermis no longer slides over the dermis like it used to.
What are two causes of calluses?
- Uneven weight distribution
- Dry skin
What is maceration?
-Softening of tissues by filling them with fluid, sweat/exudate/urine
Describe grades 1-4 of edema
1: Trace. Barely perceptable depression
2: Mild. easily identified depression, rebounds in 15 seconds.
3: Moderate. Rebounds in 15-30 seconds.
4: Severe. Rebounds in more than 30 seconds.
What are some ways to assess pain?
Pain questionnaire, pain scale, pain diary, medications, sleeping history.
What is the best predictor of protective sensation?
10 gram semmes weinstein filament.
What are you looking for with nails?
Color, thickness, shape, irregularities, ingrown, fungus
How to tell if necrosis occurred with a blister?
-If it bounces back or not when pressed down upon.
What will a partial thickness skin loss look like?
- Shallow crator, red or pink.
- May have a yellow mesh like covering.
What will a full thickness skin loss look like?
-Yellow fat, or connective tissue around muscles (white)
What will wounds extending to muscles look like?
-Dark. Pink or red with a shiny layer of fascia.
What is undermining/tunnelin?
-Separation of muscle bundles with disturbed fascia, opens tunnels between the muscles under the skin
Difference between slough and eschar?
Slough is soft, eschar is hard.
