Wound Exam and Management Flashcards
1
Q
What are the 6 purposes of a wound classification and exam?
A
- Establish a baseline status
- Determine etiology
- Note severity
- Define phase of healing
- Report changes in the wound over time
- Determine the effectiveness of interventions
2
Q
What typically causes an Arterial wound?
A
Arterial Insufficiency
3
Q
Where are Arterial wounds located?
A
Toes, feet, or lower 1/3 of the leg.
4
Q
What is the appearance of Arterial wounds?
A
Pale
5
Q
Describe the bleeding of an Arterial wound.
A
Little or none
6
Q
How much exudate does an Arterial wound have?
A
Dry or scant to small serous
7
Q
What is the typical shape of an Arterial wound?
A
Irregular
8
Q
How painful are Arterial wounds?
A
Severe, relieved by dependent position (standing)
9
Q
What are other features of Arterial wounds?
A
- Dry skin
- absent pulses
- brittle nails
10
Q
What is typically the cause of Neuropathic wounds?
A
Insensitivity or Diabetes
11
Q
Where are Neuropathic wounds typically located?
A
Plantar surface of foot
12
Q
What is the appearance of a Neuropathic wound?
A
Pale
13
Q
Describe the typical bleeding of a Neuropathic wound.
A
Brisk
14
Q
Describe the exudate of a Neuropathic wound.
A
Very little serous or serosanguineous
15
Q
What is the shape of a Neuropathic wound?
A
Punched out circle
16
Q
How painful are Neuropathic wounds?
A
Little or none
17
Q
What are other features of a Neuropathic wound?
A
- Warm skin
2. Pulses may be present or absent
18
Q
What typically causes a Pressure wound?
A
Pressure
19
Q
Where are pressure wounds typically located?
A
Bony prominences
20
Q
What is the appearance of a pressure wound?
A
Depends on the stage
21
Q
Describe the bleeding of a pressure wound.
A
Varies
22
Q
Describe the exudate of a pressure wound.
A
Varies
23
Q
Describe the shape of a pressure wound.
A
Defined edges.
24
Q
Describe the pain associated with a pressure wound.
A
Varies by depth, location, and structures involved.
25
What is the cause of a Venous wound?
Venous insufficiency
26
What is the typical location of a venous wound?
Lower 1/3 of leg, medial aspect of leg, proximal to medial malleolus
27
What is the typical color of a venous wound?
Pinkish red
28
Describe the bleeding of a venous wound.
Ooze
29
T/F: venous wounds typically have a lot of exudate.
True
30
What is the typical shape of a venous wound?
Irregular rounded edges
31
Are Venous wounds typically painful?
Mild, relieved by elevation
32
What are other features of Venous wounds?
1. Dermatitis
2. Hyperpigmentation
3. Palpable pulses
33
What are the 5 considerations with wound measurement?
1. There are a lot of different ways to assess/measure a wound
2. Regardless of method you need to be consistent
3. Take it the same way EVERY time
4. Use the same unit of measure
5. Have the same person measure (if possible)
34
How often is wound measurement typically done?
Once per week.
35
What are the two main methods of wound measurement?
The "Greatest" and The Clock
36
How is the greatest method performed?
The greatest length (cephalic-to-caudal) of the wound X the greatest width (perpendicular to cephalic-to-caudal) = surface area cm^2
37
Inflates the wound size
a. The "Greatest"
b. The Clock
a. The "Greatest"
38
Reliable
a. The "Greatest"
b. The Clock
a. The "Greatest"
39
Less used
a. The "Greatest"
b. The Clock
b. The Clock
40
Requires more precision
a. The "Greatest"
b. The Clock
b. The Clock
41
Measures consistent diameters
a. The "Greatest"
b. The Clock
b. The Clock
42
Well known (most common of measurements)
a. The "Greatest"
b. The Clock
a. The "Greatest"
43
Measures different diameters at different times b/c diameters change as size and shape change.
a. The "Greatest"
b. The Clock
a. The "Greatest"
44
How is The Clock method performed?
Length is measured as 12-6
Width is measured at 9-3
Length x Width = Surface Area cm^2
45
How is Tracing (aka plainimetry) performed?
Trace the wound on acetate or plastic wrap then transfer it to graph paper and count boxed.
46
T/F: Tracing (plainimetry) is difficult to learn but inexpensive.
F: Tracing is EASY to learn and inexpensive.
47
T/F: Tracing (plainimetry) has good intra and intertester reliability.
True
48
T/F: Tracing (doesn't allow for much detail such as tunnels, undermines, and wound tissues.
F: These are easy to draw in and use different colors for.
49
How is photography of a wound performed?
Wound is photographed on grid film. Surface area is calculated by counting the squares.
50
What can be done to show relative size of a photographed wound?
Position a linear measure near it
51
When is accuracy compromised with a photographed wound?
when wound is on a curved surface.
52
When is wound photography best?
documentation for reimbursement and legal issues. Demonstrates changes in wound.
53
Define Tunnels.
Cavities along fascial planes b/w layers under the skin.
54
Define Undermines.
Cavities beneath the wound edges.
55
How do you assess/measure tunnels or undermines?
1. Moisten cotton-tipped applicator w/ sailine or sterile water.
2. Insert it into the undermined/tunneled areas all around the perimeter.
3. At the endpoint press cotton-tipped applicator up and mark the area of bulging skin with a pen.
4. Connect the dots Measure length x width and subtract wound surface area.
- Can also measure at clock points or longest tunnel.
56
What is the most common method of reporting healing progress?
Percentage healing per week = 1 - current cm^2/previous cm^2 x 100
57
What are the limitations of basic wound depth assessment?
Can measure deepest spot, but reproducibility is not good b/c wound bed surfaces are irregular and fill irregularly. Value is controversial because of inaccuracy.
58
What is wound depth a good indication of?
Proliferation
59
How is assessment of wound depth performed?
1. Insert cotton-tipped applicator into wound bed.
2. Hold stick w/ fingers at wound skin surface edge
3. Keep fingers there and place stick along a metric ruled measured.
4. Record distance from end of cotton-tipped applicator to fingers at wound skin surface edge.
60
If the wound measured 42 cm2 last week and measures 32 cm2 this week, what is the percentage wound healing.
(1-32/42) x 100 = 24%
61
What are two alternative ways for measuring wound depth?
Jeltrate and Saline
62
What is Jeltrate and how does it work?
An alginate hydrocolloid used by dentist. Rapidly setting plastic poured into wound. Provides a positive mold of wound that can be placed into graduated cylinder and record the water displacement.
63
T/F: While Jeltrate is a good tool for measuring wound depth, it can be harmful to wound tissues.
F: Jeltrate is not harmful to wound tissues.
64
What kind of wounds can you do Would Volume via Saline?
can only be used if wound is perpendicular to line of gravity.
65
How is wound volume via saline performed?
1. Start with roughly the amount of saline you want in the syringe.
2. Saline is dropped into wound cavity until it is filled.
3. Subtract the end mount of saline from the start to get the wound volume.
4. Remove the saline from wound with a 4x4
66
What does color tell you about a wound?
provides an estimate of percentages of each tissue type within wound bbed.
67
What does Granulation look like and what does it mean?
pale red to beefy red (shiny, oily looking).
| This is HEALTHY tissue, we want LOTS of this.
68
What does Epithelialization look like and what does it mean?
white (really thin and comes from the wound edges)
69
What does Slough look like and what does it mean?
yellow. this is dead tissue (bad, do not want this as it doesn't allow tissue to heal b/c it prevents granulation and epithelialization.)
70
What does Eschar look like and what does it mean?
brown to black, can be hard and dry or soft, but not a scab which is just coagulated blood. This is dead tissues that has been around longer (bad, do not want this as it doesn't allow tissue to heal b/c it prevents granulation and epithelialization.)
71
What IS Erythema?
damage to blood vessels in epidermis most likely due to pressure.
72
What phase is Erythma a measure of?
inflammatory
73
How do Erythema appear on lightly pigmented skin? Darkly pigmented?
Erythema is nonblanchable redness is lightly pigmented skin or darkening in darkly pigmented skin.
74
What measurement methods can you use to measure Erythema?
the "greatest" method or the clock method
75
What does streaking or erythema projecting a significant distance signal?
possible infection that has entered the blood strem
76
What does Hemosiderin Staining look like and what is it a symptom of?
dark pigments close to wound edges - it is a symptom of wound chronicity or repeated injury .
77
What type of wound is more common with Hemosiderin Staining?
venous wounds
78
What is Ecchymosis?
bruising - damage to the dermis
79
How does Ecchmosis appear on lightly pigmented skin? Darkly pigmented?
Purple discoloration on lightly colored skin, deep purple color and darkly pigmented skin.
80
What is another name for Ecchymosis?
Purple Ulcer
81
What type of skin loss does Eccymosis represent?
Full thickness skin loss
82
With Ecchymosis, is skin in tact or rubbed off?
either!
83
How does Ecchymosis occur?
Acute injury results in hemorrhage and clotting which cuts off oxygen to tissues resulting in hypoxia and ischemia. If blood is not reabsorbed, tissue necrosis results.
84
What is an effective way at healing purple ulcers?
Pulsed ultra sound via acoustic streaming and cavitation.
85
What is skin temperature an objective measure of?
circulation
86
What can skin temperature be used to monitor?
- Circulatory response to treatment.
| - Inflammation
87
What is normal good temp in areas of good circulation?
About 95 deg F
88
What does increased skin temperature indicate?
inflammation and/or infection
89
What does decrease skin temperature indicate?
wound chronicity
90
When irrigating a wound, what temperature saline do you want to use?
warm, room temp and stop healing for 6-8 hours.
91
Where are calluses typically found?
plantar surface of the foot
- medial great toe
- metatarsal heads
- heel
92
What is the fxn of a callus?
Protective fxn of skin to shearing forces of bone on shoe surface.
93
What can a callus be indicative of regarding the bone?
an underlying bony pathology
94
What does hemorrhage on a callus probably indicate?
ulceration beneath
95
What happens to a callus if it is not treated?
build up continues and shear forces are increased
96
If you see blood in a callus, what should you do?
open the callus to allow the wound to heal.
97
What can decreased hair in an area indicate?
decreased circulation
98
On an extremity, what does the point where hair ends point to?
Where impaired circulation begins (should have hair all the way to your toes.)
99
What role do hair follicles contribute to in wound healing?
contribute epidermal cells for resurfacing partial thickness wounds.
100
What is the prognosis for wound healing if there is no t hair?
worse
101
When looking at a toe nail, what should you look at?
Color
Thickness
Shape
Irregularities
102
What abnormalities might you find in a toe nail and who should you refer out to for them?
Funal or pseudomonas infections, ingrown nails, hypertrophic nail. Refer to physician.
103
Blisters are a result of trauma to what dermal layer?
epidermis
104
Blisters are often fluid filled, what does clear fluid indicate? bloody/brown?
clear = superficial trauma
| bloody/brown trauma deeper than epidermis
105
What does it mean if a Blister roof bounces back? Soft, spongy, or boggy?
bounce back = only mild deep tissue congestion (damage)
| soft = tissue congestion and necrosis
106
While unroofing a blister is controversial, what does Wendy think?
Better to leave closed and use pulsed ultrasound.
107
What is Turgor in a tissue?
Resistance to tissue deformation
108
What happens to tissue turgor as you age?
decreases in aging skin
109
How can you assess tissue turgor? (2)
1. Pick up tissue w/ thumb and forefinger and observe how tissue responds.
2. Rub across skin to feel sliding of epidermis from dermis secondary to weakened epidermal-dermal junction
110
What two ways can pain be assessed?
1. Visual Analog Scale
| 2. Pain Questionnaire
111
What does maceration look like?
think prune-like skin after a bath or the white skin when you take a band-aid off.
Appears white w/ a soft, soggy texture. May be described as prunish.
112
How does maceration occur?
Softening of a tissue by soaking until connective tissue fibers are so dissolved that the tissue components can be teased apart.
113
What should be done with maceration?
Needs to be protected from pressure and shear as it breaks down easily.
114
What does a malodorous wound indicate?
infection or necrosis
115
What does a sweet smell of a wound usually associated with?
pseudomonas colonization (bacteria)
116
What does an ammonia smell usually associated with?
colinization of proteus (bacteria)
117
Why is a moist environment preferable to a wound? (2)
1. Prevent desiccation
| 2. Allow efficient migration of epidermal cells
118
For what period of time is wound drainage normal?
48-72 hours
119
What does Exudate contain?
dead cells and debris
120
What does Transudate look like?
clear fluid
121
What color drainage may indicate pseudomonas?
thick, green
122
What color drainage may indicate proteus?
thick, brown
123
Wound Drainage: Sanguineous
Color:
Consistency:
What it means:
Wound Drainage: Sanguineous
Color: Red
Consistency: Thin
What it means: New blood vessel growth or disrupted blood vessels
124
Wound Drainage: Serosanguineous
Color:
Consistency:
What it means:
Wound Drainage: Serosanguineous
Color: Light red/pink
Consistency: Thin
What it means: Normal during inflammatory and proliferative phases
125
Wound Drainage: Serous
Color:
Consistency:
What it means:
Wound Drainage: Serous
Color: Clear
Consistency: Thin
What it means: Normal during inflammatory and proliferative phases
126
Wound Drainage: Seropurulent
Color:
Consistency:
What it means:
Wound Drainage: Seropurulent
Color: Cloudy yellow/tan
Consistency: Thin
What it means: Impending wound infection
127
Wound Drainage: Purulent
Color:
Consistency:
What it means:
Wound Drainage: Purulent
Color: Yellow, tan, green
Consistency: Thick
What it means: wound infection
128
How should wound drainage be recorded subjectively?
1. None
2. Scant
3. Moderate
4. Copious
129
How should wound drainage be recorded more objectively?
As a percentage of dressed affected (60% of 4x4 or 90% of two layers of abd pad)
130
What are 4 systemic signs of wound infection?
1. Increased temp
2. Elevated WBC count
3. Confusion/agitation
4. Red streaks from wound
131
What are 5 local signs of wound infection?
1. Redness (rubor)
2. Heat (calor)
3. Edema (tugor)
4. Pain (dolor)
5. Exudate
132
Other than systemic and local signs, how can wound infection be determined?
Determined by colony count via culture (> 10,000 organisms/mL)
133
What are the 3 types of culture methods?
1. Tissues (shave off a portion of wound bed, best method however loosing some healthy tissue)
2. Needle aspiration
3. Qualitative swab
134
What makes Edema painful?
pressure on nociceptors
135
What phase is Edema part of?
Inflammatory
136
What exactly is Edema?
Fluid excess in the tissues secondary to overload of interstitial or intracellular fluids.
137
How does Edema block the spread of infection?
blocking lymphatic system after trauma
138
Edema is an indication of what 3 impairments?
1. Circulatory impairment (venous test)
2. Heart Failure (bilateral)
3. Limb dependence
139
What are the 2 main types of edema?
1. Non-pitting edema
| 2. Pitting edema
140
Describe skin in non-pitting edema.
Skin stretched and shiny, underlying tissue is hard
141
Is non-pitting edema painful or painless?
painful
142
What are the 2 other names for Non-pitting edema?
1. Traumatic edema
| 2. Brawny edema
143
How does a Pitting edema respond when pressed?
Indentation from finger pressed down for 5 seconds and remains after finger is removed.
144
Pitting edema is an indication of what 4 impairments?
1. Heart failure
2. Venous insufficiency
3. Lymphedema
4. Limb dependence
145
Is pitting edema painful or painless?
painless
146
```
How is pitting edema graded?
0 =
1+ =
2+ =
3+ =
4+ =
```
```
0 = none
1+ = minimal (0 - 1/4 inch)
2+ = moderate (1/4 - 1/2 inch)
3+ = severe (1/2 - 1 inch)
4+ = very severe (1 inch)
```
147
What is bilateral edema associated with? (1)
systemic problem
148
What is unilateral edema associated with? (8)
1. Chronic venous insufficiency
2. Lymphedema
3. Abscess
4. Osteomyelitis
5. Charcot's joint
6. Popliteal aneurysm
7. depedence
8. Revascularization
149
What is unilateral edema of sudden onset associated with?
DVT
150
What will untreated edema result in?
It will clog the lymphatic system and result in fibrosis
151
What two ways can you measure edema?
1. Girth
| 2. Volmetry
152
How is a Girth measurement performed for Edema?
Measure circumference of the limb at different locations (cm)
153
How is Volumetry measurment performed for Edema?
1. Can use a plexiglass container w/ an offset output
2. Fill volumeter w/ tepid water
3. Place limb in water
4. Catch overflow in graduated cylinder
5. Measure amount of H2O displaced
6. Repeat on opposite limb
