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