Wound Exam Flashcards
when should patients be assessed for the potential development of wounds?
upon admission to a HCF - because if a pt gets a pressure wound during admission this can leads to negative billing effects
which five items must be sterile for sterile techniques? which item must also be sterile for clean techniques?
- equipment, gloves, field, dressings, and instruments
- instruments must be sterile for clean techniques
when are sterile techniques appropriate (3)
- pts at high risk of infection
- invasive procedures
- sharp wound debridement
when (1) and where (2) are clean techniques appropriate
- routine wound care
- subacute care
- home care
describe an appropriate sterile procedure (6)
- handwashing
- maintain gloved hands above waist in line of sight
- touch wound with only sterile items
- open wound only prior to use
- clean technique to apply noncontact bandages
- discard sterile supplies if contaminated
describe an appropriate clean procedure (5)
- handwashing
- used clean gloves on a clean field
- only use sterile instruments
- prevent supply contamination
- minimize dressing handling by only touching the outer edges
describe an appropriate dressing removal protocol (3)
- gently lift barrier from surrounding skin
- note amount, type, color, and odor of dressing
- discard dressing and gloves according to facility protocol
what are classifications of wounds we must consider prior to treatment
aterial, venous, neuropathic, pressure, and burns that can be superficial/partial/deep or red/yellow/black
what are the five ways we describe a wound
- classification
- location
- size and depth
- wound base and edges
- exudate
what is a slough
yellow fibrinous tissue that contains fibrin, pus, and proteinaceous material
what is an eschar
necrotic tissue that is leathery and dry
how do you describe the location of a wound
in relation to bony landmarks
how do you describe the size and depth of a wound
LxWxD
tunneling and undermining (o’clock)
fistula
sinus tract
how do you describe the wound base and edges
tissue color, type, and anatomical structures involved (such as fat, BVs, bone, fascia, tendons, etc)
what are the five types of exudate
- sanguineous
- serosanguinous
- serous
- seropurulent
- purulent
what does sanguineous exudate indicate
new blood vessel growth or disruption of local circulation
what does serosanguineous exudate indicate
normal during inflammatory and proliferative phases of healing
what does serous exudate indicate
normal during inflammatory and proliferative phases of healing
what does seropurulent exudate look like and what does it indicate
cloudy, yellow/tan, thin, watery
may be the first sign of impending wound infection
what does purulent exudate look like and what does it indicate
yellow, tan, green, thick, opaque, odorous
signals wound infection
on what scale can you describe exudate
none scant minimal (<33%) moderate (33-67%) copious (>67%)
describe the pitting scale
1+ 0-1/4 in
2+ 1/4-1/2 in
3+ 1/2-1 in
4+ >1 in
describe the capillary refill test
light pressure over each digit for 2-3 seconds, in arterial disease digits will remain blanched >3s
how do you perform the rubor of dependency test
pt is supine and limb elevated to 45 degrees for about 1 minute
what do you look for in rubor of dependency test when the leg is elevated?
the foot will begin to blanch in the presence of arterial insufficiency when elevated according to the procedure
what do you look for in the rubor of dependency test when the leg is returned to rest
normal - foot should return to pink within 15s
arterial disease - foot will take >30s to return to color and will be dark red
what is the venous filling time test
measure of venous integrity in a normal venous system (valvular problems could bias the test)
leg elevated to 45 for a minute then returned to rest
what is a normal and abnormal venous filling time test
normal: 15 seconds for veins to refill
arterial disease: >30 s refill
what is the ABI and what is a normal value
ankle brachial index - use of a BP cuff and doppler probe to determine systolic BP at brachial and dorsalis pedis arteries (normal approx 1.0-1.2 mmHg)
an individual has normal sensation when _____ monofilament is felt.
an individual has protective sensation when _____ monofilament is felt
4.17 and 5.07
