Wound Exam Flashcards
Subjective
Demographics Med dx Med/sx hx Hx of present wound Associated complaints Current and recent meds Risk factors for not healing PLF Prior and current activity level Living situation Psych concerts Pt goals
Gross screening - integumentary
Edema
Scar tissue
Skin condition
Nail condition
Gross screening - edema
Pitting
Measurement
Gross screening - scar tissue
Appearance
Mobility
Gross screening - skin condition
Color Tug at Cleanliness Dermatitis Dry skin Abrasions or cuts Hair loss, shiny skin, molting Callouses or corns
Gross screening - nail condition
Color
Shape
Thickness
Wound assessment - MEASURE
Measure Exudate, odor Appearance Suffering (pain) Undermining Recognize inflammation Edge and periwound
Wound - measure
Length Width Depth All in centimeters Use clock method; anatomical position Digitization or tracing
Medications; current and recent
Diuretics DM Anti-inflammatory Immunosuppressant Abx Anticoagulants Analgesics Herbal Home remedies
Risk factors for non healing 1.
Smoking, alc, drug use Inadequate nutrition/hydration GERD DM PAD Renal disease Immunosuppression Aging
Risk factors for non healing 2
Certain meds Decreased functional status Sedentary lifestyle High levels of stress Infection Paresthesia Incontinence Psych impairment
PLF
Assistance
Equipment
ADLS
Prior and current activity level
Daily activities
Exercise- what, how much?
Does wound interfere?
Living situation
Type Stories Lives with? Support services? Do you drive?
Psychosocial concerns
Quality of life issues Isolation Cosmetics and self image Chronic illness Caregiver stress Healthcare expenses/lost wages Occupational/lifestyle changes Palliative care
Exudate and odor
Amount (zero, min, mod, max, copious)
Type
Odor
Appearance (wound base)v
Epithelial, granulation, necrotic tissue
Ecchymotic tissue, coagulum
Exposed structure
Adipose and fascia
Recognize inflammation
Nerds (superficial) And stonees (deep)
Edge
Flat, attached Unattached Raised Punched out Rolled/epibole
