Wound Care Examination Flashcards
What are the normal lab values of Hgb? Hcrt? Blood glucose? WBC? albumin?
Hgb = Women: 12-16 g/dL, Men: 14-18 g/dL
Hcrt = Women: 38-46%, Men: 42-54%
Glucose = 70-110 mg/dL
WBC = 4500-11k
Albumin = 3.5-5.5 g/dL
Why is it important to ask if patients have had wounds before?
previous wound in the same place makes it more difficult to treat
- pt expectations and perceptions about wound healing are very important as well
Why would you need to screen urogenital system in wound healing?
incontinence is correlated with an increased risk of pressure ulcers
wound measurement technique that measures the longest part of the wound x longest perpendicular line
direct method
wound measurement technique that measures the longest 12-6 measurement x longest 9-3 measurement
clock method
wound measurement technique that uses a clear sticker placed on the wound that is traced, then paper is stuck into chart; count squares for area
square-counting method/ tracing
when would it be indicated to use volumetric measurements for wound size?
tunnelling wounds
What characteristics are necessary to document?
- Wound bed
- Wound edges
- Presence of tunneling/ undermining
- Wound drainage
- wound odor
What characteristics of the wound bed should be noted?
- Granulation tissue
- Necrotic tissue - slough or eschar; adherent vs nonadherent to wound bed
- Other structures- fascia, bone, muscles, staples, etc.
What characteristics of the wound edges should be noted?
- distinctness - irregular vs well defined
- thickness- hyperkeratosis
- color
- attachement to base of wound (attached heal more quickly)
What characteristics of the wound drainage should be noted?
- Type: serous (n), sanguineous (n), sersanguinous (n), purulent (inf), or seropurulent (inf)
- Color: clear (n), pale yellow(n), red, dark brown, blue-green (inf)
- consistency: thin and watery (n), thick (inf)
- amount: none (dessicated), minimal (n), moderate (n), copious (inf)
What are the periwound characteristics that should be documented?
- structure and quality - age related skin, hydration, turgor, calluses, scar formation
- color - redness
- edema - pitting edema scale
- temp
- presence of hair (v insuf often see loss of hair)
What are pulse grades given for circulation?
0 = absent 1+ = diminished pulse 2+ = normal pulse 3+ = bounding or accentuated
What is the normal capillary refill time?
<3s
What are the monofilament measurements for sensoring testing?
- 17 (1 gm) = decreased sensation
- 07 (10 gm) = loss of protective sensation RED FLAG; increased risk of ulcers
- 10 (75 gm) = absent sensation
Standard in wound care, and in Arterial Vascular assessments - Ratio; LE pressure/arm pressure
Ankle Brachial Index (ABI)
taking BP at various area of the body; looking for a drop (will be a small one naturally as move distal, but is it significant amt); Don’t want a drop of >20! if taken, usually take ABI first, and this is a progression of it: taken at high thigh, low thigh, below knee, and above ankle
Segmental Pressures
Circulation test: elevate extremity testing ~60*; looking at plantar surface of, foot hold for 1 minute; is there color change?
Rubor of dependency
- (+) Test = whiteness/palor noted after 60 seconds of elevation, then immediate redness when sit pt up and bring foot back to dependent position
- Indicates Areterial Insufficiency
Circulation test: • pt supine, elevate extremity testing ~60*; looking at dorsum of foot hold for 1 minute return pt to dependent position how long does it take for color to return
Venous filling time
- Normal Venous Filling Time = 5 – 20 seconds
- <5 seconds = Venous Insufficiency
- > 20 seconds = Arterial Insufficiency
What are some wound healing assessment tools?
- Bates-Jensen Wound Assessment Tool (BWAT) previously PSST
- Pressure Ulcer Scale of Healing (PUSH)
- Sussman Wound Healing Tool (SWHT)
What are local clues to infection?
- Redness disproportionate or streaks*** (out of wound margins)
- Increased temp over wider area (not just at wound)
- Swelling disproportionate
- New onset or increase in pain
- Thick copious drainage
- Drainage white, dark yellow, green, or blue - Changes in drainage color/odor/thickness
- Distinctive odor
What are systemic clues to infection?
- Fever
- Malaise
- Leukocytosis
- Mental status change
- Tachycardia
- Hypotension
What is the difference between inflammation and infections?
- inflammatory responses are local to the wound and don’t extend much beyond the injury where infection does and has systemic effects
- inflammation follows the normal phases of healing if treated appropriately, infection plateaus and there are changes in the granulation tissue not consistent with proper healing
How do you diagnose wound infection?
- Tissue Biopsy (gold standard)
- Fluid Aspiration
- Swab Culture (used by PTs)
What are indications of a swab culture?
- Pt. exhibits signs and symptoms of infection
2. Pt. presents with a nonhealing wound despite appropriate wound management
What is the procedure of a swab culture?
- Obtain physician’s order
- Debride necrotic tissue and rinse with saline - Clean to get to actual wound bed, so you’re not just pulling from the surface/what isn’t penetrating wound
- Remove and discard soiled gloves
- Obtain a culturette and label it with date, pt’s name, and site cultured
- Put on clean gloves
- Follow a zig zag pattern (see pic) to sample all areas of wound bed
- Rotate the applicator while traveling over the wound bed
- Replace the applicator into the culturette
- Squeeze the ampoule of fluid at the bottom to bathe the applicator
- Place culturette in a labeled biohazard bag and send to lab
- Perform separate cultures on each wound
What is diagnosis based on in terms of etiology?
- Depth
- Staging System (pressure ulcers)
- Wagner (diabetic ulcers)
- Degree (burns)
What is a good prognostic indicator?
20-40% decrease in wound surface area within 2-4 weeks
- indicates wound is responding and full closure will take place
