Wound Examination Flashcards
What are some wound specific questions to ask?
- when/how did wound begin?
- have any tests been performed?
- are you on any medication for your wound?
- any wound related pain?
- what has been/is currently being done on the wound?
- is your wound improving?
What are the two systems that should be screened in those with wounds?
- GI
- genitourinary/reproductive
What should be asked when screening the GI system?
- nutrition intake
- supplementation
- continence
- BMI
What should be asked when screening the urogenital system?
- incontinence
- poorly controlled diabetes
- UTI’s
What are some tests for the Cardio/pulm review?
- HR
- BP
- RR
- Edema
- pulse ox
What are some tests for the MSK review?
- structure
- posture
- ROM
- strength
What are some tests for the neuromuscular review?
- mobility
- transfers
- gait
- balance
What are some tests for the integ review?
- breif screen of skin
- skin integrity
- skin color/formation
- nail and hair growth
What are some tests for BF?
- pulses
- ABI
- Rubor of dependency
- capillary refill
- venous filling time
- transcutaneous oxygen monitoring
- toe pressures
- doppler studies
When examining a wound what are the 12 things to exam?
- location
- pulses
- periwound temp
- periwound characteristics
- odor
- color
- shape (circle/oval, round, irregular)
- size
- depth
- drainage
- wound edges
- signs of infection
What is a fistula?
- a tunnel that connects with a body cavity or organ
What types of tissue can be found in the wound bed?
- granulation tissue
- necrotic tissue (black eschar, slough) adherent or non-adherent
- other structures (bone, tendon, capsule)
How do colors describe the wound bed?
Red:
- ready to heal appearance with definite boarders
- graduation tissue is present and revascularization
Yellow:
- pus, debris, fibrin, slough, and yellow exudate present which may require cleansing and minor debridement to promote healing
- may require use of topical antimicrobial if wound is unusually contaminated
Black:
- necrotic tissue/eschar may be present
- may include pus, fibrin, and other cellular components that inhibit granulation tissue
What is the difference in yellow slough and fibrin?
Slough:
- produced by autolysis
- soft and mushy
- product of inflammatory phase
- snot like consistency
Fibrin:
- yellow but more fibrous in appearance
- can be mistaken as connective tissue
What type of drainage can come out of a wound?
- serous: yellow
- sanguineous: bloody
- serosanguinous: yellow w/ blood tinge
- purulent: milky, pus-like, white, green, yellow
What is normal drainage for a wound?
- serous
- sanguineous (normal in response to trauma)
- serosanguineous
What drainage wound indicate a possible infection for a wound?
- purulent
- seropurulent
What is the interpretation for the color of drainage?
- clear/pale yellow: normal
- red: fresh blood
- dark brown: dried blood
- blue-green: probable pseudomonas infection
How can wound edges be described?
- distinctness
- attachment to base of wound
- thickened/rolled (epiboly, hyperkeratotic - callus)
- evidence of epithelialization, maceration, scarring, pigment changes
How wound you document skin temperature?
- increased, decreased, or normal
What are some different colors of skin?
- normal
- erythema (blanchable vs Non blanchable)
- pale or cyanotic
- hyperpigmentation
How would you test for pitting edema?
- firmly press thumb or index finger into area for 5 seconds
How would you interpret a test for pitting edema?
1+: barely perceptible depression (<2mm)
2+: easily identifiable depression, rebounds <15 sec (2-4mm)
3+: depression rebounds 15-30 sec (5-7mm)
4+: depression last >30 sec (>7mm)
What are different odors for wounds?
Sickly sweet: pseudomonas
Ammonia-like: proteus infection
Musky: typical malignant tissue
What are some signs of infection?
- erythema disproportionate to size of wound
- poorly defined erythema boarder
- fever
- warmth disproportionate to size of wound
- could have induration
What are the three phases of healing?
- inflammatory
- proliferation
- maturation & remodeling
What goes in the objective section of a wound examination?
Systems review:
- integ
- cardio pulm (vitals)
- MSK
- neuromuscular
- cognition
Wound exam:
- all 12 aspects of the wound examined
- any special tests performed
What goes in the assessment section of a wound examination?
- interpretation of individuals tests and measures
- integration of the test and measure data with other info collected during history
- determination of: diagnosis amenable to PT management and prognosis (including goals)
- development of POC
What are positive indicators of a good prognosis?
- A1c, ABI, previous healing, and compliance with compression (ALL good levels)
- 20-40% decrease in wound surface area w/in 2-4 weeks
What are negative indicators of a bad prognosis?
- A1c, smoking, ABI (ALL bad levels)
- no decrease in size or signs of improvement w/in 2 weeks
What are some good intervention’s for wound healing?
- education
- debridement
- dressing selection and modification
- biophysical agents
- mobility training
- referrals
What is the role of the PTA in wound care?
- allowed to follow POC and treatment
- can conduct objective tests and measure goals
- can measure wounds
- describe wounds (color, drainage, odor, wound bed, periwound, etc.)
- circumferential measurements
