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Integumentary > Wound Assessment > Flashcards

Wound Assessment Flashcards

1
Q

what are some intrinsic risk factors for wounds

A
  • nutrition/hydration
  • medication
  • infection
  • incontinence
  • immobility (calf mm)
  • co morbid disease
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2
Q

what are some extrinsic risk factors for wounds

A

mechanical forces

  • pressure
  • shear
  • friction
  • moisture
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3
Q

how do you classify an acute wound

A
  • surgical/non surgical

- burn first-fourth

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4
Q

how do you classify a chronic wound

A
  • venous ulcer
  • arterial ulcer
  • diabetic ulcer
  • pressure ulcer
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5
Q

what is the location of diabetic foot ulcer

A
  • plantar forefoot
  • plantar toes/heel
  • DIP/PIP (dorsal)
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6
Q

what are characteristics of a diabetic foot ulcer

A
  • high bacterial load

- painless

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7
Q

why is a diabetic foot ulcer painless

A

due to neuropathy

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8
Q

how is a diabetic foot ulcer graded

A

Wagner Grade

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9
Q

Wagner 0

A
  • pre ulceration
  • healed ulcer
  • bony deformity
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10
Q

Wagner 1

A

Superficial ulcer w/o subcutaneous involvement

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11
Q

Wagner 2

A
  • thru subcutaneous

- may expose bone, tendon, ligament, joint capsule

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12
Q

Wagner 3

A

osteitis, abscess or osteomyelitis

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13
Q

Wagner 4

A

digit gangrene

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14
Q

Wagner 5

A

foot gangrene

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15
Q

where are pressure ulcers located

A

wound over bony prominence

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16
Q

how do you determine the severity of pressure ulcer

A

Stage I - IV

deep tissue injuries

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17
Q

Pressure Ulcer Stage 1

A

unblanchable erythema

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18
Q

Pressure Ulcer Stage 2

A
  • partial thickness
  • thru epidermis
  • 100% pink
  • intact blister
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19
Q

Pressure Ulcer Stage 3

A
  • full thickness
  • into dermis
  • damage/necrosis of tissue
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20
Q

Pressure Ulcer Stage 4

A
  • extensive destruction

- exposed mm, tendon, bone

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21
Q

when do you determine a pressure ulcer is unstageable

A

covered by black eschar

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22
Q

Deep tissue injury is identified as

A

discoloration

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23
Q

partial thickness is defined as

A

loss of epidermis and down into but not thru the dermis

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24
Q

examples of partial thickness wound

A
  • abrasions
  • skin tears
  • blisters
  • skin graft
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25
Q

characteristics of partial thickness wound

A

100% pink

NO NECROSIS

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26
Q

full thickness is defined as

A

thru the dermis, into the subcutaneous tissue

may have exposed structures

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27
Q

arterial and venous ulcers are graded as

A

partial and full thickness

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28
Q

what is the location of arterial ulcers

A
  • wound on dorsal foot/toes

- lateral leg

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29
Q

how do you determine the severity of arterial ulcer

A

partial or full thickness

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30
Q

what are some characteristics of arterial ulcer

A
  • dry
  • painful
  • ischemic LE
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31
Q

what position should you place a arterial ulcer in

A

let it dangle to promote blood flow

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32
Q

what is the location of venous ulcer

A
  • b/w the knee and ankle

- medial is more common

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33
Q

how do you determine the severity of venous ulcer

A

partial or full thickness

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34
Q

what are some characteristics of venous ulcer

A
  • irregular border
  • heavily draining
  • edematous LE
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35
Q

what techniques help determine wound dimension

A
  • two dimensional (L x W)
  • three dimensional (LxWxD)
  • tracings
  • planimetry: visual imaging
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36
Q

how do you describe the depth of a wound

A
  • undermining

- tunneling

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37
Q

undermining

A

tissue loss parallel to skin surface

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38
Q

tunneling/sinus tracts

A

tissue loss into depths of the wound

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39
Q

Epibole

A

Wound edges are rolled

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40
Q

exudate

A

wound drainage containing dead cells and debris

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41
Q

how do you describe the amount of drainage

A
  • none
  • scant/small
  • moderate
  • large
  • copious
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42
Q

how do you describe the color of drainage

A
  • serous
  • serosanguineous
  • sanguineous
  • purulent
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43
Q

serous

A

clear

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44
Q

serosanguineous

A

blood tinged

45
Q

sanguineous

A

bloody drainage

46
Q

purulent

A

brown, green, white

47
Q

sweet odor

A

pseudomonas

48
Q

foul odor

A

anaerobic bacteria

49
Q

periwound erythema

A

red and warm

50
Q

periwound induration

A

firmness to tissue

51
Q

Periwound maceration

A

too moist

52
Q

Periwound echymotic

A

bruised

53
Q

periwound cyanotic

A

bluish skin indicative of ischemia

54
Q

what is edema

A

the presence of fluid in the intracellular tissue space

55
Q

how do you describe edema

A
  • pitting

- non pitting

56
Q

how to grade pitting edema

A 
0= not present 
1 = minimal 
2+= moderate
3+= severe
57
Q

how do you measure edema

A
  • volumetric

- girth

58
Q

volumetric

A

water displacement

59
Q

girth

A

measurements at determined intervals

60
Q

what does LOPS stand for

A

Loss of protective sensation

61
Q

how do you check if sensory loss is suspected

A

monofilament

62
Q

what size monofilament is used as an indicator for risk of DFU

A

5.07 monofilament

63
Q

describe the categories for LOPS

A

0= no loss

1= loss of protective

2= loss of protective w/ high pressure, poor circulation

3= hx of plantar ulceration, neuropathetic fx, amputation

64
Q

neuropathic fx

A

charcot foot

65
Q

what is the relationship b/w temp and ulceration

A

change in temp greater than 4 deg = risk of ulcer

66
Q

a pulse grade of 1+

A

barely felt

67
Q

a pulse grade of 2+

A

diminished

68
Q

when she you address and document pain

A

when pain is rated > 3

69
Q

the plan of care must include

A 
procedure
location
parameters
duration 
frequency
70
Q

what indicates if pressure, diabetic foot, and venous ulcer is unlikely to progress to healing

A

if it does not reduce in size 30-50% in 2-4 weeks

71
Q

what is an example of expected outcome

A
  • increase granulation
  • decrease necrosis
  • decrease wound size
72
Q

STG or LTG

pt will be independent with dressing change in 2 wks for pt. convenience thru reduction of office visit

A

STG

73
Q

STG or LTG

secure diabetic offloading footwear to decrease risk of DFU recurrence from high to low in 12 weeks

A

LTG

74
Q

according to the article when should a wound be reassessed

A
  • after a pt. returns from operating room
  • noticeable deteriorates
  • odor or purulent exudate
  • any change in condition
  • after pt. returned form another facility
75
Q

granulation tissue

A

deep pink or red is characterized by an irregular granular surface that resembles raspberries

76
Q

clean nongranulating tissue

A

deep pink or red and smooth (nongrannular) or striated (when muscle fibers are exposed)

77
Q

new epithelial tissue

A

light pink or slightly lavender and dry

78
Q

healing wounds are characterized

A

increasing amounts of granulation tissue and later by epithelialization

79
Q

what signifies a wound in a inflammatory phase

A

significant amounts of slough or eschar

80
Q

according to the article what is epibole

A

a common complication of chronic wounds that include pre mature closure of the wound edges preventing epithelialization and wound closure

81
Q

how are closed wound edges characterized

A

dry, normally pigmented skin that extends to the junction with the wound bed

82
Q

what are signs of heavy bioburden

A
  • sudden deterioriration in quantity or quality of granulation tissue that is edematous, pale, and nongranular
  • persistent high volume wound exudate and increased pain
83
Q

when are clean but not granulating wounds seen

A

end of the inflammatory phase, when debridement is complete but granulation tissue has not began forming

84
Q

are all ulcers staged

A

only pressure ulcers

not arterial, venous, neuropathy

85
Q

how long should you delay staging

A

until the deepest viable tissue layer is exposed

86
Q

wound healing by primary intention key assessment factors

A
  • approximation by 3rd post op day
  • drainage
  • evidence of infection
  • presence of palpable healing ridge along the incisions
87
Q

what does the presence of palpable haling ridge indicate

A

granulation tissue formation

normally palpable by 5th post op day

88
Q

wound healing by secondary intention key assessment factors

A
  • location
  • dimensions/depth
  • tunneling/undermining
  • stage
  • appearance of wound base
  • status of wound edges
  • evidence of heavy bioburden
  • status of surrounding tissue
89
Q

If your pt is post surgery would their wound be considered acute or chronic?

A

acute

90
Q

If your pt has diabetes and suffers from ________________ they may not feel pain, and therefore may not be aware of a wound

A

neuropathy

91
Q

If your pt’s wound (pressure ulcer) has exposed tendon and bone w/ extensive destrustion, how would it be staged?

A

stage 4

92
Q

When would you stage a pressure ulcer as a Deep Tissue Injury?

A

If there is discoloration, and clear damage below the wound (no visible)

93
Q

If your patient presents w/ cool hairless legs w/ a wound on their lateral lower limb you would suspect which type of ulcer?

A

arterial ulcer

94
Q

If your patient presents w/ tree trunk legs and LE swelling w/ an ulcer on their medial LE you would suspect which type of ulcer?

A

venous ulcer

95
Q

Your pt comes to you with a wound and they report that the wound on their lateral LE is dry and very painful. Which Ulcer do you suspect?

A

arterial ulcer

96
Q

Your pt comes to you with a wound and they report large swollen LE, a wound w/ irregular borders, and wound location on their medial LE. Which ulcer do you suspect?

A

venous

97
Q

Which wound length and width measurement has the best inter-rater reliability?

A

longest length x longest width

98
Q

What is undermining? And what causes it?

A

When the ulcer perimeter is not the true perimeter of the wound; due to shear forces

99
Q

What is a common standardized method to measuring wound dimensions?

A

clock method

100
Q

What kind of wound are you more likely to find undermining and tunneling?

A

pressure ulcers

101
Q

What is tunneling?

A

Tissue loss into the depths of the wound creating a tunnel

102
Q

What may need to occur on a wound that has unattached edges? Why?

A

Surgical Debridement; So keritinocytes can do their job

103
Q

How would hypergranulation tissue present on a pt?

A

When the beefy red granulation tissue grows outside the wound boundaries

104
Q

In order to check exudate/drainage what do we look at?

A

the bandage

105
Q

Where do we palpate LE pulses?

A

dorsalis pedis and post tib

106
Q

What needs to be included when you photograph a wound?

A

pt. initial, date, wound location

107
Q

What factors should be considered for predicting wound healing?

A

duration, size, comparison to documentation

108
Q

What are the primary goals for wound healing?

A
  • increase granulation tissue
  • decrease necrosis
  • decrease wound size
  • educate pt./caregiver

Integumentary (10 decks)

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