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DPT 773 - Integumentary > Wound Assessment and Documentation > Flashcards

Wound Assessment and Documentation Flashcards

1
Q

What factors are considered in the general assessment of a patient with a wound?

A
  • comorbidities
  • social history
  • HPI
  • pain
  • ROM
  • strength
  • sensation
  • mobility
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2
Q

How do comorbidities affect wound healing?

A

They can impair tissue perfusion/oxygenation, slow immune response, and affect overall healing.

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3
Q

How does age impact wound healing?

A

Aging decreases collagen synthesis, sensation, circulation, and immune response, slowing healing.

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4
Q

What role does nutrition play in wound healing?

A

Inadequate nutrition increases wound incidence, healing complications, and delays healing time.

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5
Q

Which medications negatively affect wound healing?

A
  • Steroids (>30-40 mg/day)
  • chemotherapy
  • NSAIDs can impair
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6
Q

What comorbidities contribute to impaired wound healing?

A

Vascular disease, diabetes, edema, immunodeficiency, and collagen disorders.

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7
Q

How does smoking affect wound healing?

A

It decreases tissue perfusion and oxygenation, increasing infection risk and graft/flap necrosis.

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8
Q

What impact does alcohol abuse have on wound healing?

A

It increases malnutrition risk, delays medical assistance, and raises injury risk.

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9
Q

What is the difference between acute and chronic wounds?

A

Acute wounds heal predictably, while chronic wounds have delayed or arrested healing.

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10
Q

How does pain assessment contribute to wound evaluation?

A

Pain patterns aid in differential diagnosis and understanding wound characteristics.

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11
Q

Why is ROM important in wound assessment?

A

ROM restrictions can cause abnormal pressure patterns and mobility issues, affecting wound healing.

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12
Q

How does impaired sensation impact wound management?

A

It prevents automatic offloading due to pain perception, increasing risk of further injury.

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13
Q

What aspects are assessed in wound-specific evaluation?

A

Location, size, depth, undermining, drainage, odor, edges, and periwound condition.

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14
Q

How should wound location be documented?

A

Using anatomically correct terminology, documenting side and body surface, and referencing landmarks.

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15
Q

How is wound size measured?

A

Using longest length and widest width; wound area is length × width.

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16
Q

What is tunneling & undermining in wound assessment?

A
  • 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.
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17
Q

How is wound depth measured?

A

Using a direct measurement method, documented with exact depth in centimeters.

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18
Q

What is wound mapping?

A

Using diagnostic ultrasound to assess wound and peri-wound tissue, identifying depth, edema, and abscesses.

19
Q

What are the key components of the wound bed?

A
  • Granulation tissue, necrotic tissue, slough, eschar (black), fascia, and other exposed structures.
20
Q

What is granulation tissue?

A

Beefy-red, cobblestone-like tissue made of small blood vessels and connective tissue.

21
Q

What is eschar?

A

Necrotic, dead tissue, typically black, brown, or tan, impeding wound healing.

22
Q

What is slough in wound assessment?

A

Soft, moist, devitalized tissue that is mucous-like, stringy, and yellow or green.

23
Q

How is the Red-Yellow-Black system used?

A

It quantifies wound bed tissue types and documents them as percentages.

24
Q

What is bioburden in wound assessment?

A

The presence of microbes in a wound, with colonization indicating normal flora and infection indicating microbial invasion.

25
Q

What is hyperspectral imaging?

A

A technique that measures oxy- and deoxy-hemoglobin to assess local perfusion.

26
Q

How does photodigital planimetry improve wound measurement?

A

It provides quantitative wound measurement and can calculate wound surface area.

27
Q

What is bacterial fluorescence imaging?

A

A method that uses endogenous fluorescence to detect bacteria, indicating infection presence.

28
Q

How should wound drainage be documented?

A

By type, color, consistency, and amount, providing insights into wound status.

29
Q

What can wound odor indicate?

A

The presence of infection or other underlying wound issues.

30
Q

How are wound edges evaluated?

A

By assessing distinctness, color, attachment, re-epithelialization, and pigment changes.

31
Q

What is the importance of documenting periwound condition?

A

It helps assess factors like temperature, edema, hair presence, and skin quality.

32
Q

What are SMART goals in wound management?

A

Goals that are Specific, Measurable, Attainable, Relevant, and Time-based.

33
Q

What is a short-term goal in wound care?

A

An objective typically achieved within 30 days, aligned with progress notes.

34
Q

What is a long-term goal in wound care?

A

An expected outcome at discharge or end of the plan of care, focusing on functional improvement.

35
Q

Why is it important to set measurable outcomes in wound care?

A

To objectively evaluate progress and adjust interventions accordingly.

36
Q

What is a sample short-term goal for wound management?

A

Reduce wound size by 20% within 2 weeks, measured by length and width.

37
Q

What is a sample long-term goal for wound management?

A

Achieve full wound closure and tissue integrity within 8 weeks of treatment.

38
Q

What is the purpose of wound documentation?

A

To provide a clear, accurate record of wound characteristics and treatment progress.

39
Q

Why is using anatomical landmarks important in wound documentation?

A

It ensures consistent and accurate location documentation, improving treatment outcomes.

40
Q

What factors contribute to setting realistic goals in wound management?

A

Patient comorbidities, wound type, healing potential, and overall patient mobility.

41
Q

What should be included in a wound care progress note?

A

Changes in wound size, tissue type, drainage, patient response, and treatment adjustments.

42
Q

How does effective documentation impact wound care outcomes?

A

It guides treatment decisions, tracks progress, and improves communication among care providers.

43
Q

What are functional goals in wound management?

A

Goals that focus on improving the patient’s ability to perform daily activities.

44
Q

What is the importance of assessing pain patterns in wound management?

A

To differentiate wound types and guide pain management strategies.

DPT 773 - Integumentary (9 decks)

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