Wound Care Terminology & Documentation

Question 1

Define clock

Answer 1

• reference points
• head is always 12 o’clock and feet are always 6 o’clock

Question 2

Define length

Answer 2

• cephalad to caudal (12 to 6 o’clock)

Question 3

Define width

Answer 3

• horizontal (3 to 9 o’clock)

Question 4

Define depth

Answer 4

• deepest aspect of wound

Question 5

Define tunnel

Answer 5

• channel extending beyond open wound base
• need to document a clock reference

Question 6

Define sinus tract

Answer 6

• dead end channel

Question 7

Define undermining

Answer 7

• wound edge erosion, fascia has separated from deeper tissue

Question 8

Define fistula

Answer 8

• channel originating in a wound that penetrates a body cavity

Question 9

Define eschar

Answer 9

• brown or black necrotic tissue

Question 10

Define epithelialization

Answer 10

• wound bed has translucent or white cell layer

Question 11

Define granulation tissue

Answer 11

• pink/red, granular appearing moist tissue containing connective tissue, blood vessels for wound repair & closure

Question 12

Define slough

Answer 12

• soft moist dead fibrous tissue, stringy loose tissue in wound bed

Question 13

Define exudate

Answer 13

• drainage

Question 14

Define serous exudate

Answer 14

• clear & watery (inflammation & proliferation stages of healing)

Question 15

Define sanguineous exudate

Answer 15

• bloody due to blood vessel damage

Question 16

Define serosanguinous exudate

Answer 16

• pink/reddish, watery drainage (inflammation & proliferation stages of healing)

Question 17

Define purulent/pus exudate

Answer 17

• yellow, green, tan cloudy
• may indicate infections & may have an odor
• bad sign

Question 18

Bacterial infection in acute wounds

Answer 18

• pain, erythema, swelling, loss of function, & increased temperature

Question 19

arterial infection in chronic wounds

Answer 19

• change in quantity, color, odor of drainage
• presence of pus
• minimal erythema of wound edges
• local pain
• increased temperature
• abnormal or absent granulation tissue (turned light pink or went away
• cellulitis (inflammation of the soft tissue
• change in periwound sensation (going from no pain to pain suddenly)

Question 20

Superficial bacterial infection NERDS

Answer 20

Nonhealing
Exudate increasing
Red frail granulation
Debris on wound surface
Smell (after irrigating the wound)

Question 21

Deep bacterial infection STONES

Answer 21

Size increases
Temperature of periwound increases
Osseous structures are exposed (bone)
New areas of breakdown are present
Erythema, edema, & exudate present
Smell is present

Question 22

Documentation of wounds MEASURE

Answer 22

Measure - length x width x depth
Exudate - quality & quantity
Appearance - wound bed/tissue type %
Suffering - pain level/functional loss
Undermining - clock system
Re-evaluate - every week, infection
Edge - periwound