Wound Assessment and Documentation Flashcards
What factors are considered in the general assessment of a patient with a wound?
- comorbidities
- social history
- HPI
- pain
- ROM
- strength
- sensation
- mobility
How do comorbidities affect wound healing?
They can impair tissue perfusion/oxygenation, slow immune response, and affect overall healing.
How does age impact wound healing?
Aging decreases collagen synthesis, sensation, circulation, and immune response, slowing healing.
What role does nutrition play in wound healing?
Inadequate nutrition increases wound incidence, healing complications, and delays healing time.
Which medications negatively affect wound healing?
- Steroids (>30-40 mg/day)
- chemotherapy
- NSAIDs can impair
What comorbidities contribute to impaired wound healing?
Vascular disease, diabetes, edema, immunodeficiency, and collagen disorders.
How does smoking affect wound healing?
It decreases tissue perfusion and oxygenation, increasing infection risk and graft/flap necrosis.
What impact does alcohol abuse have on wound healing?
It increases malnutrition risk, delays medical assistance, and raises injury risk.
What is the difference between acute and chronic wounds?
Acute wounds heal predictably, while chronic wounds have delayed or arrested healing.
How does pain assessment contribute to wound evaluation?
Pain patterns aid in differential diagnosis and understanding wound characteristics.
Why is ROM important in wound assessment?
ROM restrictions can cause abnormal pressure patterns and mobility issues, affecting wound healing.
How does impaired sensation impact wound management?
It prevents automatic offloading due to pain perception, increasing risk of further injury.
What aspects are assessed in wound-specific evaluation?
Location, size, depth, undermining, drainage, odor, edges, and periwound condition.
How should wound location be documented?
Using anatomically correct terminology, documenting side and body surface, and referencing landmarks.
How is wound size measured?
Using longest length and widest width; wound area is length × width.
What is tunneling & undermining in wound assessment?
- Tunneling: Sinus tracts extending from the wound, documented using clock terms to identify position.
- Undermining: Tissue destruction under intact skin, commonly seen in pressure ulcers.
How is wound depth measured?
Using a direct measurement method, documented with exact depth in centimeters.
What is wound mapping?
Using diagnostic ultrasound to assess wound and peri-wound tissue, identifying depth, edema, and abscesses.
What are the key components of the wound bed?
- Granulation tissue, necrotic tissue, slough, eschar (black), fascia, and other exposed structures.
What is granulation tissue?
Beefy-red, cobblestone-like tissue made of small blood vessels and connective tissue.
What is eschar?
Necrotic, dead tissue, typically black, brown, or tan, impeding wound healing.
What is slough in wound assessment?
Soft, moist, devitalized tissue that is mucous-like, stringy, and yellow or green.
How is the Red-Yellow-Black system used?
It quantifies wound bed tissue types and documents them as percentages.
What is bioburden in wound assessment?
The presence of microbes in a wound, with colonization indicating normal flora and infection indicating microbial invasion.
What is hyperspectral imaging?
A technique that measures oxy- and deoxy-hemoglobin to assess local perfusion.
How does photodigital planimetry improve wound measurement?
It provides quantitative wound measurement and can calculate wound surface area.
What is bacterial fluorescence imaging?
A method that uses endogenous fluorescence to detect bacteria, indicating infection presence.
How should wound drainage be documented?
By type, color, consistency, and amount, providing insights into wound status.
What can wound odor indicate?
The presence of infection or other underlying wound issues.
How are wound edges evaluated?
By assessing distinctness, color, attachment, re-epithelialization, and pigment changes.
What is the importance of documenting periwound condition?
It helps assess factors like temperature, edema, hair presence, and skin quality.
What are SMART goals in wound management?
Goals that are Specific, Measurable, Attainable, Relevant, and Time-based.
What is a short-term goal in wound care?
An objective typically achieved within 30 days, aligned with progress notes.
What is a long-term goal in wound care?
An expected outcome at discharge or end of the plan of care, focusing on functional improvement.
Why is it important to set measurable outcomes in wound care?
To objectively evaluate progress and adjust interventions accordingly.
What is a sample short-term goal for wound management?
Reduce wound size by 20% within 2 weeks, measured by length and width.
What is a sample long-term goal for wound management?
Achieve full wound closure and tissue integrity within 8 weeks of treatment.
What is the purpose of wound documentation?
To provide a clear, accurate record of wound characteristics and treatment progress.
Why is using anatomical landmarks important in wound documentation?
It ensures consistent and accurate location documentation, improving treatment outcomes.
What factors contribute to setting realistic goals in wound management?
Patient comorbidities, wound type, healing potential, and overall patient mobility.
What should be included in a wound care progress note?
Changes in wound size, tissue type, drainage, patient response, and treatment adjustments.
How does effective documentation impact wound care outcomes?
It guides treatment decisions, tracks progress, and improves communication among care providers.
What are functional goals in wound management?
Goals that focus on improving the patient’s ability to perform daily activities.
What is the importance of assessing pain patterns in wound management?
To differentiate wound types and guide pain management strategies.
