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
2
Q
what are some extrinsic risk factors for wounds
A
mechanical forces
- pressure
- shear
- friction
- moisture
3
Q
how do you classify an acute wound
A
- surgical/non surgical
- burn first-fourth
4
Q
how do you classify a chronic wound
A
- venous ulcer
- arterial ulcer
- diabetic ulcer
- pressure ulcer
5
Q
what is the location of diabetic foot ulcer
A
- plantar forefoot
- plantar toes/heel
- DIP/PIP (dorsal)
6
Q
what are characteristics of a diabetic foot ulcer
A
- high bacterial load
- painless
7
Q
why is a diabetic foot ulcer painless
A
due to neuropathy
8
Q
how is a diabetic foot ulcer graded
A
Wagner Grade
9
Q
Wagner 0
A
- pre ulceration
- healed ulcer
- bony deformity
10
Q
Wagner 1
A
Superficial ulcer w/o subcutaneous involvement
11
Q
Wagner 2
A
- thru subcutaneous
- may expose bone, tendon, ligament, joint capsule
12
Q
Wagner 3
A
osteitis, abscess or osteomyelitis
13
Q
Wagner 4
A
digit gangrene
14
Q
Wagner 5
A
foot gangrene
15
Q
where are pressure ulcers located
A
wound over bony prominence
16
Q
how do you determine the severity of pressure ulcer
A
Stage I - IV
deep tissue injuries
17
Q
Pressure Ulcer Stage 1
A
unblanchable erythema
18
Q
Pressure Ulcer Stage 2
A
- partial thickness
- thru epidermis
- 100% pink
- intact blister
19
Q
Pressure Ulcer Stage 3
A
- full thickness
- into dermis
- damage/necrosis of tissue
20
Q
Pressure Ulcer Stage 4
A
- extensive destruction
- exposed mm, tendon, bone
21
Q
when do you determine a pressure ulcer is unstageable
A
covered by black eschar
22
Q
Deep tissue injury is identified as
A
discoloration
23
Q
partial thickness is defined as
A
loss of epidermis and down into but not thru the dermis
24
Q
examples of partial thickness wound
A
- abrasions
- skin tears
- blisters
- skin graft
25
characteristics of partial thickness wound
100% pink
NO NECROSIS
26
full thickness is defined as
thru the dermis, into the subcutaneous tissue
| may have exposed structures
27
arterial and venous ulcers are graded as
partial and full thickness
28
what is the location of arterial ulcers
- wound on dorsal foot/toes
| - lateral leg
29
how do you determine the severity of arterial ulcer
partial or full thickness
30
what are some characteristics of arterial ulcer
- dry
- painful
- ischemic LE
31
what position should you place a arterial ulcer in
let it dangle to promote blood flow
32
what is the location of venous ulcer
- b/w the knee and ankle
| - medial is more common
33
how do you determine the severity of venous ulcer
partial or full thickness
34
what are some characteristics of venous ulcer
- irregular border
- heavily draining
- edematous LE
35
what techniques help determine wound dimension
- two dimensional (L x W)
- three dimensional (LxWxD)
- tracings
- planimetry: visual imaging
36
how do you describe the depth of a wound
- undermining
| - tunneling
37
undermining
tissue loss parallel to skin surface
38
tunneling/sinus tracts
tissue loss into depths of the wound
39
Epibole
Wound edges are rolled
40
exudate
wound drainage containing dead cells and debris
41
how do you describe the amount of drainage
- none
- scant/small
- moderate
- large
- copious
42
how do you describe the color of drainage
- serous
- serosanguineous
- sanguineous
- purulent
43
serous
clear
44
serosanguineous
blood tinged
45
sanguineous
bloody drainage
46
purulent
brown, green, white
47
sweet odor
pseudomonas
48
foul odor
anaerobic bacteria
49
periwound erythema
red and warm
50
periwound induration
firmness to tissue
51
Periwound maceration
too moist
52
Periwound echymotic
bruised
53
periwound cyanotic
bluish skin indicative of ischemia
54
what is edema
the presence of fluid in the intracellular tissue space
55
how do you describe edema
- pitting
| - non pitting
56
how to grade pitting edema
```
0= not present
1 = minimal
2+= moderate
3+= severe
```
57
how do you measure edema
- volumetric
| - girth
58
volumetric
water displacement
59
girth
measurements at determined intervals
60
what does LOPS stand for
Loss of protective sensation
61
how do you check if sensory loss is suspected
monofilament
62
what size monofilament is used as an indicator for risk of DFU
5.07 monofilament
63
describe the categories for LOPS
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
neuropathic fx
charcot foot
65
what is the relationship b/w temp and ulceration
change in temp greater than 4 deg = risk of ulcer
66
a pulse grade of 1+
barely felt
67
a pulse grade of 2+
diminished
68
when she you address and document pain
when pain is rated > 3
69
the plan of care must include
```
procedure
location
parameters
duration
frequency
```
70
what indicates if pressure, diabetic foot, and venous ulcer is unlikely to progress to healing
if it does not reduce in size 30-50% in 2-4 weeks
71
what is an example of expected outcome
- increase granulation
- decrease necrosis
- decrease wound size
72
STG or LTG
pt will be independent with dressing change in 2 wks for pt. convenience thru reduction of office visit
STG
73
STG or LTG
secure diabetic offloading footwear to decrease risk of DFU recurrence from high to low in 12 weeks
LTG
74
according to the article when should a wound be reassessed
- after a pt. returns from operating room
- noticeable deteriorates
- odor or purulent exudate
- any change in condition
- after pt. returned form another facility
75
granulation tissue
deep pink or red is characterized by an irregular granular surface that resembles raspberries
76
clean nongranulating tissue
deep pink or red and smooth (nongrannular) or striated (when muscle fibers are exposed)
77
new epithelial tissue
light pink or slightly lavender and dry
78
healing wounds are characterized
increasing amounts of granulation tissue and later by epithelialization
79
what signifies a wound in a inflammatory phase
significant amounts of slough or eschar
80
according to the article what is epibole
a common complication of chronic wounds that include pre mature closure of the wound edges preventing epithelialization and wound closure
81
how are closed wound edges characterized
dry, normally pigmented skin that extends to the junction with the wound bed
82
what are signs of heavy bioburden
- sudden deterioriration in quantity or quality of granulation tissue that is edematous, pale, and nongranular
- persistent high volume wound exudate and increased pain
83
when are clean but not granulating wounds seen
end of the inflammatory phase, when debridement is complete but granulation tissue has not began forming
84
are all ulcers staged
only pressure ulcers
not arterial, venous, neuropathy
85
how long should you delay staging
until the deepest viable tissue layer is exposed
86
wound healing by primary intention key assessment factors
- approximation by 3rd post op day
- drainage
- evidence of infection
- presence of palpable healing ridge along the incisions
87
what does the presence of palpable haling ridge indicate
granulation tissue formation
normally palpable by 5th post op day
88
wound healing by secondary intention key assessment factors
- location
- dimensions/depth
- tunneling/undermining
- stage
- appearance of wound base
- status of wound edges
- evidence of heavy bioburden
- status of surrounding tissue
89
If your pt is post surgery would their wound be considered acute or chronic?
acute
90
If your pt has diabetes and suffers from ________________ they may not feel pain, and therefore may not be aware of a wound
neuropathy
91
If your pt's wound (pressure ulcer) has exposed tendon and bone w/ extensive destrustion, how would it be staged?
stage 4
92
When would you stage a pressure ulcer as a Deep Tissue Injury?
If there is discoloration, and clear damage below the wound (no visible)
93
If your patient presents w/ cool hairless legs w/ a wound on their lateral lower limb you would suspect which type of ulcer?
arterial ulcer
94
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?
venous ulcer
95
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?
arterial ulcer
96
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?
venous
97
Which wound length and width measurement has the best inter-rater reliability?
longest length x longest width
98
What is undermining? And what causes it?
When the ulcer perimeter is not the true perimeter of the wound; due to shear forces
99
What is a common standardized method to measuring wound dimensions?
clock method
100
What kind of wound are you more likely to find undermining and tunneling?
pressure ulcers
101
What is tunneling?
Tissue loss into the depths of the wound creating a tunnel
102
What may need to occur on a wound that has unattached edges? Why?
Surgical Debridement; So keritinocytes can do their job
103
How would hypergranulation tissue present on a pt?
When the beefy red granulation tissue grows outside the wound boundaries
104
In order to check exudate/drainage what do we look at?
the bandage
105
Where do we palpate LE pulses?
dorsalis pedis and post tib
106
What needs to be included when you photograph a wound?
pt. initial, date, wound location
107
What factors should be considered for predicting wound healing?
duration, size, comparison to documentation
108
What are the primary goals for wound healing?
- increase granulation tissue
- decrease necrosis
- decrease wound size
- educate pt./caregiver
