Wound Assessment/Treatment Flashcards
1
Q
Things to include in wound assessment
A
- ROM
- Sensation
- Strength
- Functional mobility (bed mob, transfers, gait)
- neuromuscular coordination
- balance
- equipment used
2
Q
Examination of skin
A
- observation
- characteristics of lesion
- location/distribution of lesion
- pattern/arrangement of lesion
- exudates present
3
Q
Size and Level of Tissue Involvement
A
- Area: length x width=cm squared
- Depth: cm from wound bed to skin surface
4
Q
Length vs Width
A
length: 12:00-6:00 clock
Width: 9:00-3:00
5
Q
Wound Surface
A
- color
- tissue type (slough, necrotic, granulation etc)
- exudate amount
- exudate type
- undermining
6
Q
Surrounding Surface
A
- skin color
- erythema of intact skin
- tissue edema
- tissue induration
7
Q
Treatment Options
A
-US, hydrotherapy, pulsed lavage, hyperbaric O2, Estim, compression, UV, debridement, dressings/bandages
8
Q
Add functional component to wound goals
A
- “to be able to wear shoes in community”
- “promote independence with self care”
9
Q
Intervention of Necrotic Tissue
A
- debridement
- many types
10
Q
Types of Debridement
A
- non-selective
- selective
- enzymatic debridement
- autolytic
- biosurgical
- surgical
11
Q
Normal Hemoglobin A1c
A
6.5 or less
12
Q
Hb A1c
A
- measure blood sugar over time (30-60 days)
- glucose sticks to blood
