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.
What aspects of wound drainage do you look at?
- Color
- Odor
- Volume
Define serosanguineous discharge
-Thin, watery, pale pink discharge.
What are the four best tools for wound assessment?
- Sulsman wound healing tool
- Pressure ulcer scale for healing
- Bates Jensen wound assessment tool
- Wound healing index.
What is an angiogram?
xray of arteries and blood vessels to diagnose blockages using a dye. Invasive.
What is a cat angioplasty?
Combines xrays with computerized analysis of blood flow, less invasive than angiogram.
What is an MR angiography and how does it compare to the other imaging techniques?
-MRI of small vessels, difficult to tell arteries from veins.
What is ultrasound good for?
-Greater ole in diagnosiss of vascular disease, but can’t cut through calcifications.. Bad at IDing closed from nearly closed vessels.
What is thermography good for?
IDing areas receiving blood flow.
What is the best imaging for osteomyelitis, and what is typically used?
Nuclear medicine scans, but high levels of radiation, X-ray with MRI is typically used instead.
