Wound Evaluation Flashcards
Wound descriptors
Dimensions Subcutaneous extensions Tissue type Drainage Periwound skin color Edema Edge description Odor Pain Sensation Pressure Light touch Temp Pulses
Methods
Perpendicular
Clockwise
Photography (weekly)
Electronic
Subcutaneous extensions
Undermining: destruction of the C.T. between the dermis and subcutaneous tissue
Sinus: long, narrow opening along a fascial plane
Tunneling: a tract that connects two wounds
Tissue type
Indicates healing phase
Provides data for measuring outcomes
Helps determine optimal treatment plan for primary and secondary dressings
May help indicate other disease processes
Eschar
Black, borne, yellow, or gray fibrin
Dead cells
Dry/hard, or soft/rubbery
Dry gangrene or Wet gangrene
Yellow slough
Softer, lighter necrotic debris By-product of autolysis Beneath eschar Common in inflammatory phase Differs from adhered CT. in that it is soft and mushy, hard to grasp w/ forceps
Granulation
Red, beefy looking Angiogenesis (new formation of BV) New capillaries and extracellular matrix Anemic to bright red STSG (split thickness skin graft)
Devitalized fascia
Dull
Fibrous C.T.
around or between other tissues
Muscle
Striated Reddish when healthy Brown/grey when devitalized Sensate when healthy PAINFUL when exposed
Tendons
Shiny/stringy when healthy
Fibrous C.T. synovial fluid/fatty fluid (paratenon)
Dull or dry when devitalized
Bone
Tan
Hard to palpitate w/ metal instrument
Covered with periosteum when healthy
Dark brown when necrotic
Adipose
Shiny, yellow when healthy
Shriveled and dry when devitalized
Poorly vascularized
Frequent sources of abscess formation
Drainage
Serous: clear watery
Sanguineous: red bloody
Serosanguineous: serous w/ pink tinge
Exudate: pale yellow drainage, composed of dead cells, serum, and lysed debris, high protein content
Seropurulence: slightly thicker drainage indicative of colonized bacteria
Purulence: thick necrotic drainage
Lymph: water and dissolved proteins (mostly albumin) too large to be absorbed by the capillaries
Erythema
Abnormal red color
Indicate underlying infection
Stage 1 pressure ulcer if over boney
Superficial or partial thickness
Cyanosis
Dusky or bluish
Lack of O2 in tissue
Both arterial or venous wounds
Deep tissue injury
Repeated shear forces on in senate area
Hemosiderin
Brownish/purple Gaiter area of the leg Results from extravastion of red blood cells into interstitial tissue; the cell is lysed and hemoglobin released into the tissue Begins distally and migrates proximally Chronic venous insufficiency
Ecchymosis
Subdermal hemorrhage
Result of acute injury
Edges - Even
Typical arterial wounds
Causes punctuate appearance to the wound
Edges - Irregular
Typical of venous wounds
May occur as the wound epithelializes
Edges - Closed or Rolling
Sign of halted healing process
Cells are termed senescent, unable to reproduce
Rolled edge, epibole
Edges - Hyperkeratosis
Overdevelopment outer layer
Appears thickened skin as callus
Epithialization
Migration of epithelial cells over granulation tissue
Percentage of edges that epithelializing
Odor
Pseudomonas - sweet, greenish drainage
Putrid - indicates infection
Necrotic - extensive necrotic tissue
Musky - malignant tissue
Pain
Deep - cramping, ischemia/hypoxia, comfortable in dependent position
Throbbing, localized - infection, increases with pressure (osteomyelitis)
Superficial tenderness - exposed nerve endings, sharp shooting pains
W/ stimulation of red tissue, living muscle
Sensation
Diabetic patients
Semmes-Weinstein
Compare sides, 3*F difference is significant
Warmer - infection inflammatory
Cooler - decrease blood flow
