Wound Exam Flashcards
1
Q
Subjective
A
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
2
Q
Gross screening - integumentary
A
Edema
Scar tissue
Skin condition
Nail condition
3
Q
Gross screening - edema
A
Pitting
Measurement
4
Q
Gross screening - scar tissue
A
Appearance
Mobility
5
Q
Gross screening - skin condition
A
Color Tug at Cleanliness Dermatitis Dry skin Abrasions or cuts Hair loss, shiny skin, molting Callouses or corns
6
Q
Gross screening - nail condition
A
Color
Shape
Thickness
7
Q
Wound assessment - MEASURE
A
Measure Exudate, odor Appearance Suffering (pain) Undermining Recognize inflammation Edge and periwound
8
Q
Wound - measure
A
Length Width Depth All in centimeters Use clock method; anatomical position Digitization or tracing
9
Q
Medications; current and recent
A
Diuretics DM Anti-inflammatory Immunosuppressant Abx Anticoagulants Analgesics Herbal Home remedies
10
Q
Risk factors for non healing 1.
A
Smoking, alc, drug use Inadequate nutrition/hydration GERD DM PAD Renal disease Immunosuppression Aging
11
Q
Risk factors for non healing 2
A
Certain meds Decreased functional status Sedentary lifestyle High levels of stress Infection Paresthesia Incontinence Psych impairment
12
Q
PLF
A
Assistance
Equipment
ADLS
13
Q
Prior and current activity level
A
Daily activities
Exercise- what, how much?
Does wound interfere?
14
Q
Living situation
A
Type Stories Lives with? Support services? Do you drive?
15
Q
Psychosocial concerns
A
Quality of life issues Isolation Cosmetics and self image Chronic illness Caregiver stress Healthcare expenses/lost wages Occupational/lifestyle changes Palliative care
