Wound Eval Flashcards
1
Q
what can cause impaired wound healing?
A
- inadequate intake of protein, carbohydrates, lipids, vitamins, and minerals
- dehydration
2
Q
how many calories does normal wound healing require?
A
30-35 calories per kilogram of body weight per day
3
Q
How much fluid do patients with open wounds require?
A
30-35 mL
4
Q
Serum Albumin
A
- plasma protein
- normal: 3.5-5.5 g/dL
- decreased –> protein deficiency –> poor nutrition/malnutrition
5
Q
Serum Prealbumin
A
- Transport protein
- not affected by hydration status
- normal: 16-40 mg/dL
6
Q
Total Lymphocyte Count (TLC)
A
- measures immune function
- normal: >/= 2000 cells/mm
- decreased: immunocompromised
- increased: possible bacterial infection
7
Q
Blood Glucose/ A1c
A
- Normal: 70-115 mg/dL for A1c < 6.0%
- Increased = risk for impaired wound healing
8
Q
Creatinine
A
- Kidney Function
- Normal = 0.1-1.2 mg/dL
- increased = edema (very high sign of renal failure
9
Q
Other lab values measured
A
- RBC
- Hematocrit
- WBC
- platelet
10
Q
Wound size measurement
A
- Direct measure: length x width x depth (cm)
- Measure from longest/widest edges
- Clock position
- Depth measurement?
11
Q
Wound size - Tracings
A
EZ graft
Save for documentation
12
Q
Wound Size - Photographs
A
- Polaroid vs Digital
- Include measurement guide in photo
- Document date, name, location of wound ON PHOTO
13
Q
Tunneling
A
- cm
- Narrow passage created by separation or destruction of tissues along facial planes
- common in pressure sores and deeper wounds
14
Q
Undermining
A
- cm
- occurs when tissue edges erode leaving a large wound with a small opening
15
Q
Sinus Tract
A
Elongated cavity allowing purulent material from an abscess to drain to body surface
16
Q
Clock Method to Document
A
12 = head
6 = feet
Ex: 3.2 cm undermining from 12 to 3; 1.9 cm tunneling at 3:00 position
17
Q
Granulation Tissue
A
viable, bubbly bright beefy red tissue (good oxygen supply)
Pink or dusty = ischemia or infection (document as “clean non-granular pink tissue”)
18
Q
Necrotic Tissue
A
Non-viable tissue, breeding ground fro bacteria, document by color, consistency, and adherence
- Slough and Eschar
19
Q
Slough
A
i. Color: tan, yellow, green
ii. Consistency: stringy or mucinous
iii. Adherence: ease that it pulls away from wound base non-adherent loosely adherent firmly adherent
20
Q
Eschar
A
i. Color: black or brown
ii. Consistency: soft or hard
iii. Adherence: adherent or non- adherent
iv. Stability: stable vs. non-stable
21
Q
Adipose Tissue
A
a. Viable: yellow, globular, slippery
b. Non-viable: grayish, hard/crunchy
22
Q
Fascia
A
a. Viable: Shiny, white, thick/thin, sheath like
b. Non-viable: grayish, slimy, disintegrating
23
Q
Bones
A
a. Viable: white, solid
b. Non-viable: yellow/brown, soft –> If wound is down to level of bone possible osteomyelitis must be ruled out
24
Q
Tendons
A
a. Viable: shiny, white, fibrous, cord like
b. Non-viable: dull white/yellow/gray
25
Ligaments
a. Viable: fibrous flat, yellow/white
b. Non-viable: dull yellow/gray
26
Muscles
a. Viable: dull red, pink, striated, may contract when touched
b. Non-viable: grayish, loose fibers
27
Wound Edges
tissue perimeter
periwound
28
Types of Wound Edges
- Defined/undefined
- Attached/unattached
- Epibole (Epiboly)
- Xerosis
- Ecchymosis
- Maceration
- Erythema
- Fibrosis or induration
- Hyperkeratotic
29
Wound Drainage: Exudate - Type
Serous, Sanguineous, Serosanguineous, Purulent
30
Wound Drainage: Exudate - Color
Clear, yellow, red, dark brown, blue/green (pseudomonas infection)
31
Wound Drainage: Exudate - Consistency
Thin/watery and thick
32
Wound Drainage: Exudate - Amount
Scant, Minimal, Moderate, Heavy, Copious
33
Wound Odor
Present vs. Absent
Cleans wound prior to assessing
Descriptors: foul, sweet, pungent
34
Types of Edema
Induration
Pitting
35
Classification for pitting edema
1+ barely perceptible
2+ easily identified depression (EID), but rebounds < 15 sec
3+ EID, rebounds in 15-30 seconds
4+ EID, rebounds in > 30 sec
36
Circulation
1. Pulses --> ABI
2. Doppler US
3. Capillary refill
4. Rubor of Dependency
5. Toe pressure
37
Sensory Integrity
Semmes-Weinstein Monofilaments
5.07 loss of protective sensation
38
Pain Assessment
1. VAS
2. Pain with palpation
39
Arterial Insufficiency - Etiology
Arteriosclerosis or acute thrombosis
40
Arterial Insufficiency - Location
Lateral malleolus, anterior lower leg, toes
41
Arterial Insufficiency - Appearance
Small, shallow/deep, round with regular edges, pale, often necrotic
eschar present
42
Arterial Insufficiency - Pain
Severe, at rest, night, intermittent claudication
43
Arterial Insufficiency - Perfusion
ABI < 0.90
If < 0.5, REFERRRRR!!!
delayed capillary refill
rubor of dependency
cool to touch
diminished or absent pulses
44
Arterial Insufficiency - Periwound and general integument condition
Ischemic; shiny; taut; thin, dry, alopecia, trophic changes (thick toe nails)
45
Venous Insufficiency - Etiology
vascular incompetence
46
Venous Insufficiency - Location
Medial malleolus and medial leg
47
Venous insufficiency - Appearance
Shallow, irregular shape, moderate/high drainage, glossy,
macerated
48
Venous Insufficiency - Pain
Mild/moderate; alleviated with elevation
49
Venous Insufficiency - Perfusion
ABI 1.0 or less; Normal capillary refill; poor venous fill; warm or
normal temperature
50
Venous Insufficiency - Periwound and general integument conditions
white wound edges due to maceration; Hemosiderin staining/Lipodermatosclerosis; significant edema
51
Neuropathic- Etiology
Hyperglycemia/Diabetes Mellitus
52
Neuropathic- Location
plantar surface of foot/heel; altered pressure points
53
Neuropathic - Appearance
round; punched out; little to no drainage; necrotic base
54
Neuropathic- Pain
None... that's the problem
55
Neuropathic - Perfusion
ABI normal or may be false positive; pulses normal to absent; Normal to warm temperature
56
Neuropathic - Periwound and general integument condition
callus periwound; dry cracked skin; structural deformities (toe clawing; rocker bottom foo; Charcot foot deformity)
57
Neuropathic - Wagner Classification System
0 = No open ulcers
1 = Superficial Ulcer
2 = Deep ulcer, tendon, capsule or bone present
3 = Deep ulcer, abscess, sepsis, or osteomyelitis
4 = Localized gangrene
5 = Entire foot gangrenous
58
Pressure Ulcers - Etiology
unrelieved pressure
59
Pressure Ulcers- Location
Sacrum, greater trochanter, ischial tuberosity, posterior calcaneus, lateral
malleolus
60
Pressure Ulcers- Appearance
Deep; tunneling and undermining; eschar; profuse drainage
61
Pressure Ulcers - Pain
Sensation varies and pain varies
62
Pressure Ulcers - Perfusion
Often normal
63
Pressure Ulcers - Periwound and general integument conditions
ring of erythema; nonblanchable erythema; localized warmth; Fibrous induration; dermatitis
64
Scales for Pressure Ulcers
Sessing scale; Pressure Sore Status Tool; Braden Scale; Norton Pressure Scale
65
Braden Scale
- Prevention tool for assessing risk of ulceration
- Subscales Measure: Mobility
-- Activity
-- Sensory Perception
-- Skin Moisture
-- Nutritional Status
-- Friction and Shear
** A score of 18 or less = risk; the lower the score the greater the risk
66
Norton Risk Assessment
Subscales measure:
- physical condition
- mental condition
- activity
- mobility
- incontinence
*** a score of 16 or less = risk; lower the score, the greater the risk
67
Risk factors for pressure ulcers
Impaired mobility, Malnutrition, Impaired sensation, age, hx of previous pressure ulcers
68
Why do pressure ulcers occur?
o Combination of time and amount of pressure
o Pressure of > 32 increase risk of sore, but even lower pressures for longer period of
time can cause capillary closure.
o Shear and friction →shearing force between skin and deeper tissues →stretching
and angulation of vasculature, compromising perfusion
o Moisture increases shear forces
69
Stage I Pressure Ulcer Staging
- Nonblachable erythema
- Skin intact
- Blue/purple appearance
- Change in local tissue temperature, tissue consistency & sensation
70
Stage II Pressure Ulcer
- Super ulcer
- Blister
71
Stage III Pressure Ulcer
- Deep Ulcer
- Crater
- May have undermining
*** if you see necrosis, it is at least a stage III
72
Stage IV Pressure Ulcer Staging
- Deep ulcer
- Extensive necrosis
- Undermining/ tunneling/ sinus tracts
73
Unstageable Pressure Ulcer
Used if base of wound is obscured by eschar or slough
74
Suspected Deep Tissue Injury (Pressure Ulcer)
- Discoloration/ blood filled
- Painful
- Boggy
- May evolve to eschar
75
Cardinal Signs of Infection
- Rubor
- Calor
- Pain
- Tumor
- Odor
- Systemic signs (fever, chills, sudden shift in glucose levels)
76
How to confirm wound infection
- tissue biopsy: GOLD STANDARD
- swab culture: aerobic, anaerobic, see Meyers for procedure
77
Types of infection
Gram positive
Fungal
78
Bioburden
All tissues have a "normal amount"
When critical levels are reached = infection
79
Wound location
Quantity
Location
Shape
80
Systems review
Integument
Cardiovascular
Musculoskeletal
Neuromuscular
Gi
Ug
81
Epibole
Pizza crust
Edges of skin fold over wound
82
Xerosis
Hyper dry skin
Typically seen in diabetics
83
Maceration
White ring around wound
Too wet
84
Fibrous or induration
Palpate around wound and it feels like dough, creates indentation
85
Pruitis
Itching
Most common in diabetes
, drug hypersensitivity, hyperthyroidism
86
Urticaria
1. Smooth, red, elevated patches of skin, hives
2. Indicative of allergic response to drug or infection
