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Chronic Rehab > Wound Assessment > Flashcards

Wound Assessment Flashcards

1
Q

what are the phases of healing

A

1) hemostasis
2) inflammation
3) proliferation, granulation, contracture
4) remodeling

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2
Q

what are a big component of hemostasis

A

platelets

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3
Q

what are a big component of inflammation

A

neutrophils

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4
Q

what are a big component of proliferation, granulation and contracture

A

macrophages, lymphocytes, angiocytes, fibroblasts, keratinocytes

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5
Q

what are a big component of remodeling

A

fibrocytes

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6
Q

what impairs wound healing

A 
Medications
Immunosuppression
Chronic conditions such as DIABETES and peripheral arterial disease
Infection
Poor hygiene
Malnutrition
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7
Q

when should wound assessment be done

A

regularly

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8
Q

when should diabetics assess their feet and what should they wear

A

diabetics should assess their feet DAILY and wear appropriate footwear (socks and shoes).

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9
Q

what do you FIRST attain in wound assessment

A

HISTORY

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10
Q

what is the second thing attained in would assessment

A

etiology

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11
Q

what questions do you ask for etiology

A

Is the wound surgical or nonsurgical? Is it acute or chronic?

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12
Q

describe chronic wounds

A

fail to follow the orderly (and timely) process of healing

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13
Q

what is the third part of wound assessment

A

determine wound location, depth and size

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14
Q

what is wound size and depth measured in

A

cm

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15
Q

what is the fourth part of wound assessment

A

Exudate amount and consistency

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16
Q

yellowish fluid with small amounts of blood

A

serosanguineous

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17
Q

fluid containing mostly blood

A

sanguineous

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18
Q

what is the fifth part of wound assessment

A

Document tunneling or undermining

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19
Q

narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation.

A

tunneling wound

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20
Q

occurs when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound’s edge

A

wound undermining

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21
Q

what is the sixth part of wound assessment

A

Describe the appearance of the wound bed

22
Q

reddish new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process

A

granulation tissue

23
Q

dead or devitalized tissue.

A

necrotic tissue

24
Q

a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite, or as a result of anthrax infection.

A

eschar

25
Q

how would you describe the appearance of the wound bed

A

What color is the wound tissue?

Granulation tissue, necrotic tissue, eschar

26
Q

what is the seventh part of wound assessment

A

Describe the peri-wound skin (the skin surrounding the wound)

27
Q

what is the eighth part of wound assessment

A

Pain or odor?

28
Q

what can be a source of abscess

A

Tissue destruction underlying intact skin that results in dead space

29
Q

involves large portion of the wound edge

A

undermining

30
Q

narrow, involves small amount of wound edge and may have significant length

A

tracts/tunnels

31
Q

dead tissue, usually cream or yellow in colour

A

slough

32
Q

signs and symptoms of wound infection

A 
Odor
Purulent exudate
Erythema
Edema of the surrounding skin
Increased pain (or new report of pain)
Friable wound tissue
Wound depth extends to the bone (osteomyelitis) 
Increased wound size or a delay in healing
33
Q

Wound depth extends to the bone

A

osteomyelitis

34
Q

what method should you use to measure a wound on a patient

A

clock method to measure, with 12 o’clock being the patient’s head and 6 o’clock oriented to the patient’s feet

35
Q

how do you measure wound depth

A

by inserting a sterile swab into the deepest area of the wound. Place a gloved forefinger on the swab at skin level.

36
Q

what is important to remember when measuring a wound

A

Take 2 or 3 measurements to ensure that you are correct!

37
Q

what are the causes of diabetic foot ulcers

A

Peripheral arterial disease
Neuropathy
Callus formation
Musculoskeletal (foot) deformities

38
Q

localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear

A

pressure ulcer

39
Q

stage 1 pressure ulcer

A

INTACT skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue

40
Q

stage 2 pressure ulcer

A

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister.

41
Q

stage 3 pressure ulcer

A

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

42
Q

stage 4 pressure ulcer

A

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. May include undermining and tunneling.

43
Q

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

A

deep tissue injury

44
Q

describe deep tissue injury signs

A

painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

45
Q

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough or eschar in wound bed

A

unstageable pressure ulcer

46
Q

what is the pressure ulcer prevention methods

A 
Identify risk factors
Identify patients at risk for pressure ulcers
Skin Care
Nutrition
Mechanical Loading
Support Surfaces
Education
47
Q

senses that are typically impaired

A

•Visual•Hearing•Olfactory ad gustatory•Balance disorder

48
Q

what language should be used for people with disablities

A

•Put the person before the disability•Describe what the has, not who the person is

49
Q

best way to communicate if deaf

A

•Sign•Lip read•Write notes

50
Q

most commonly administered in an institution
professional medical caregivers
no time restriction
life prolonging therapy is not avoided

A

palliative care

51
Q

more numerous
commonly administered at home
MUST be considered terminal
focus on COMFORT not treatment

A

hospice care

Chronic Rehab (18 decks)

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