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Practice topics Exam 2 > Wound Management 2 and 3 > Flashcards

Wound Management 2 and 3 Flashcards

1
Q

Standardized measures

A

There are a lot - esp for pressure ulcers

Difficult to quantify a wound though

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2
Q

Location

A

First thing you need to do

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3
Q

Location - top of foot with hammer toes - you are suspecting

A

Neuropathic foot
Pressure ulcer
Pressure on neuropathic foot is causing the pressure ulcer (if they are ambulating)

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4
Q

Location - venous insufficiency

A

Generally located in the gaiter area

Just above the medial malleolus (no higher than the boots)

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5
Q

Location - wounds in areas that tend to bear pressure - think

A

neuropathic origin - especially in the mobile patient

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6
Q

Size and shape

A

What you look at after location

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7
Q

Size and shape - arterial

A

Defined circular lesion

Looks like punched out

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8
Q

Size and shape - venous ulcer

A

irregular wound margins

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9
Q

Size and shape - most common measurement

A

Linear measures

Finding the longest and the widest points of the wound

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10
Q

Size and shape - documentation

A

Remember to record the direction of the length and width measurements (lateral to medial, or head to foot)

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11
Q

Size and shape - clock method

A

Saying longest is from 10 to 4 oclock and widest is from 1 to 7 oclock

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12
Q

Size and shape - grid

A

Position grid over the wound and then you measure the grid in a variety of diff ways
This is still linear - but now counting the cm squares
Gives you an area concept

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13
Q

Size and shape - Linear measures - pros

A

Fast
Easy
Inexpensive
High intra and inter rater reliability

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14
Q

Size and shape - linear measures - cons

A

May overestimate the size of the wound

Not always indicative of how well a wound is healing

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15
Q

Size and shape - Tracings

A

Used in conjunction with linear measurements

Variety of tools - acetate sheets, plastic bags, special measurement sheets

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16
Q

Size and shape - tracing - pros

A

Fast
Easy
Reliable
Can be retained as part of medical record

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17
Q

Size and shape - Photos - what impacts the image

A 
Distance
Lighting 
Body part position
Still a 2D image of a 3D product 
Special cameras and film are available
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18
Q

Depth

A

3rd dimension of a wound

Distance from the surface of the skin to the deepest portion of the wound bed

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19
Q

Depth - con

A

Reliability is questionable

Undermining, tunnels, or sinus tracts can be a problem with measuring depth

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20
Q

Depth - ways to measure

A

Calibration sticks with markings on the side of it - put it in deepest part
Metal tipped probes
Special rulers
Cotton tipped applicators

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21
Q

Depth - ways to measure - problem with cotton tipped applicators

A

Wound will not heal with foreign materials and these cotton tipped applicators will leave cotton fibers in the wound!

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22
Q

Volume measures

A

Only in wounds without tunnels or significant undermining

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23
Q

Volume measures - how

A

Place an amount of liquid (sterile solution) into the wound

Use a calibrated syringe and withdraw that fluid and keep track of the amount of fluid added to the wound

24
Q

Volume measures - con

A

Wound exudate/slough may impede the measurement and clog the syringe

25
Q

Tool for tunneling and undermining measurement

A

Wound stick tunneler

26
Q

Drainage

A

In addition to wound itself - make sure you look at the dressing
Clean wound and then look to see if wound is producing exudate

27
Q

Drainage - measurement

A

Can weight dressing and then weigh it again in about 3 days to see how much weight of exudate you have
Often will say minimal, moderate, severe for amount

28
Q

Drainage - document what in addition to amount

A

Consistency
Color
Odor

29
Q

Drainage - thin, watery, pink

A

Serosanguineous

Normal with acute inflammation

30
Q

Drainage - thin, watery, clear

A

Serous

Normal with acute inflammation

31
Q

Drainage - Thick or thin, opaque, creamy yellow

A

Purulent
Does not always mean infection
Pus = cellular debris

32
Q

Drainage - thick, opaque yellow, green, rust

A

purulent - this one does mean infection

usually will have some odor too

33
Q

Drainage - thick, stringy white or pale yellow

A

fibrosis
fibrotic wound is healing badly
disarray in the proliferative phase - impairs granulation

34
Q

Exudate vs. Slough

A

Exudate - fluid and cells generated by healing process, can be thick or stringy
Slough = devitalized necrotic tissue mixing with exudate to make slough (if you dry out slough = eschar)

35
Q

Slough description

A

Moist devitalized host tissue
Can be firmly attached or loose
Some say it is liquefying necrosis
Recent suggestion of biofilm related slough

36
Q

Slough - Color

A

Color will vary from creamy, yellow, and tan (depnds on hydration)

37
Q

Slough - Consistency

A

May be slimy, gelatinous, stringy, clumpy, or fibrous in consistency

38
Q

Slough - contains

A

Proteinaceous tissue
Fibrin
Neutrophils
Bacteria

39
Q

Wound edge/margin

A

Moisture level
Shape
Condition

40
Q

Wound edge/margin - rolled edges

A

Tight and contracted
Epithelialiazation that gets to wound margin and starts to roll over and then stops because hits the bottom and has nowhere else to go
Indicates that the wound is maintaining in a chronic proliferative stage

41
Q

Wound edges can also be

A

Macerated - too much fluid

Drying out - can make them crumbly too

42
Q

Neuropathic ulcer - often have what

A

Callus around them that have to be debrided away
Remarkably dry
Right over metatarsal bone

43
Q

Wound bed/base - look at

A

Color
Necrotic tissue
Slough or fibrin deposits
Anatomic structures visible?

44
Q

Wound bed/base - color

A

Pale red or pink = arterial issue

Beefy red = good granulation tissue

45
Q

Wound bed/base - Necrotic tissue

A

Adhered
Amount in relationship to size of wound bed
Can use percentage for saying how much is covered with necrotic tissue

46
Q

Eschar is typically what on the wound? (convex or concave)

A

Concave

Tends to be smooth

47
Q

Arterial ulcers tend to have what characteristics

A

Very dry surrounding area that is lacking hair follicles
Very dry in general too
Symmetrical wound margins
Might see cellulitis going up the leg

48
Q

Culture methods

A

Biopsy is the gold standard - is invasive though, usually requires local, and is expensive
Swab - most common
Bone probe

49
Q

Culture swab

A

1 Clean wound
2 Select cleanest area
3 Using firm pressure, move swab over selected area rotating 360 degrees
4 Avoid wound edges
5 Transport specimen - needs to be done according to protocol

50
Q

Culture methods - when would you bone probe

A

When suspect osteomyelitis
When probe, it breaks apart, can send a piece to culture
Best for bone is diagnostic imaging though

51
Q

When would you do a culture?

A

Is suspect infection

Usually you don’t bother - but you would if have chronic wound that won’t heal or something else stands out at you

52
Q

Surrounding tissue/Peri wound area - look at

A

Color
Edema
Condition

53
Q

Surrounding tissue/Peri wound area - Color

A

Darkened pigmented - may indicate damaged tissue

Redness - inflammation, cellulitis

54
Q

Surrounding tissue/Peri wound area - Edema

A

Need to measure it
How far does it extend
Is it pitting

55
Q

Surrounding tissue/Peri wound area - Condition

A

Dry, flaky
Macerated (wet)
Indurated (hard)
Lipodermatosclerosis (hard but with specific color, bounces back a little more too)

56
Q

Surrounding tissue/Peri wound area - Symmetry

A

Cellulitis - usually asymmetrical surrounding

Inflammation - usually more symmetrical surrounding

57
Q

Foot deformities/Pressures

A

Look for calluses, corns
Malformed nails
Make note of any deformities - hallux valgus, pes planus, pes cavus, hammer toes

Practice topics Exam 2 (15 decks)

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