Wound Care Terminology & Documentation Flashcards
Define clock
- reference points
- head is always 12 o’clock and feet are always 6 o’clock
Define length
- cephalad to caudal (12 to 6 o’clock)
Define width
- horizontal (3 to 9 o’clock)
Define depth
- deepest aspect of wound
Define tunnel
- channel extending beyond open wound base
- need to document a clock reference
Define sinus tract
- dead end channel
Define undermining
- wound edge erosion, fascia has separated from deeper tissue
Define fistula
- channel originating in a wound that penetrates a body cavity
Define eschar
- brown or black necrotic tissue
Define epithelialization
- wound bed has translucent or white cell layer
Define granulation tissue
- pink/red, granular appearing moist tissue containing connective tissue, blood vessels for wound repair & closure
Define slough
- soft moist dead fibrous tissue, stringy loose tissue in wound bed
Define exudate
- drainage
Define serous exudate
- clear & watery (inflammation & proliferation stages of healing)
Define sanguineous exudate
- bloody due to blood vessel damage
Define serosanguinous exudate
- pink/reddish, watery drainage (inflammation & proliferation stages of healing)
Define purulent/pus exudate
- yellow, green, tan cloudy
- may indicate infections & may have an odor
- bad sign
Bacterial infection in acute wounds
- pain, erythema, swelling, loss of function, & increased temperature
arterial infection in chronic wounds
- 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)
Superficial bacterial infection NERDS
Nonhealing
Exudate increasing
Red frail granulation
Debris on wound surface
Smell (after irrigating the wound)
Deep bacterial infection STONES
Size increases
Temperature of periwound increases
Osseous structures are exposed (bone)
New areas of breakdown are present
Erythema, edema, & exudate present
Smell is present
Documentation of wounds MEASURE
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
