Wound Management 2 and 3 Flashcards
Standardized measures
There are a lot - esp for pressure ulcers
Difficult to quantify a wound though
Location
First thing you need to do
Location - top of foot with hammer toes - you are suspecting
Neuropathic foot
Pressure ulcer
Pressure on neuropathic foot is causing the pressure ulcer (if they are ambulating)
Location - venous insufficiency
Generally located in the gaiter area
Just above the medial malleolus (no higher than the boots)
Location - wounds in areas that tend to bear pressure - think
neuropathic origin - especially in the mobile patient
Size and shape
What you look at after location
Size and shape - arterial
Defined circular lesion
Looks like punched out
Size and shape - venous ulcer
irregular wound margins
Size and shape - most common measurement
Linear measures
Finding the longest and the widest points of the wound
Size and shape - documentation
Remember to record the direction of the length and width measurements (lateral to medial, or head to foot)
Size and shape - clock method
Saying longest is from 10 to 4 oclock and widest is from 1 to 7 oclock
Size and shape - grid
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
Size and shape - Linear measures - pros
Fast
Easy
Inexpensive
High intra and inter rater reliability
Size and shape - linear measures - cons
May overestimate the size of the wound
Not always indicative of how well a wound is healing
Size and shape - Tracings
Used in conjunction with linear measurements
Variety of tools - acetate sheets, plastic bags, special measurement sheets
Size and shape - tracing - pros
Fast
Easy
Reliable
Can be retained as part of medical record
Size and shape - Photos - what impacts the image
Distance Lighting Body part position Still a 2D image of a 3D product Special cameras and film are available
Depth
3rd dimension of a wound
Distance from the surface of the skin to the deepest portion of the wound bed
Depth - con
Reliability is questionable
Undermining, tunnels, or sinus tracts can be a problem with measuring depth
Depth - ways to measure
Calibration sticks with markings on the side of it - put it in deepest part
Metal tipped probes
Special rulers
Cotton tipped applicators
Depth - ways to measure - problem with cotton tipped applicators
Wound will not heal with foreign materials and these cotton tipped applicators will leave cotton fibers in the wound!
Volume measures
Only in wounds without tunnels or significant undermining
Volume measures - how
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
Volume measures - con
Wound exudate/slough may impede the measurement and clog the syringe
Tool for tunneling and undermining measurement
Wound stick tunneler
Drainage
In addition to wound itself - make sure you look at the dressing
Clean wound and then look to see if wound is producing exudate
Drainage - measurement
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
Drainage - document what in addition to amount
Consistency
Color
Odor
Drainage - thin, watery, pink
Serosanguineous
Normal with acute inflammation
Drainage - thin, watery, clear
Serous
Normal with acute inflammation
Drainage - Thick or thin, opaque, creamy yellow
Purulent
Does not always mean infection
Pus = cellular debris
Drainage - thick, opaque yellow, green, rust
purulent - this one does mean infection
usually will have some odor too
Drainage - thick, stringy white or pale yellow
fibrosis
fibrotic wound is healing badly
disarray in the proliferative phase - impairs granulation
Exudate vs. Slough
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)
Slough description
Moist devitalized host tissue
Can be firmly attached or loose
Some say it is liquefying necrosis
Recent suggestion of biofilm related slough
Slough - Color
Color will vary from creamy, yellow, and tan (depnds on hydration)
Slough - Consistency
May be slimy, gelatinous, stringy, clumpy, or fibrous in consistency
Slough - contains
Proteinaceous tissue
Fibrin
Neutrophils
Bacteria
Wound edge/margin
Moisture level
Shape
Condition
Wound edge/margin - rolled edges
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
Wound edges can also be
Macerated - too much fluid
Drying out - can make them crumbly too
Neuropathic ulcer - often have what
Callus around them that have to be debrided away
Remarkably dry
Right over metatarsal bone
Wound bed/base - look at
Color
Necrotic tissue
Slough or fibrin deposits
Anatomic structures visible?
Wound bed/base - color
Pale red or pink = arterial issue
Beefy red = good granulation tissue
Wound bed/base - Necrotic tissue
Adhered
Amount in relationship to size of wound bed
Can use percentage for saying how much is covered with necrotic tissue
Eschar is typically what on the wound? (convex or concave)
Concave
Tends to be smooth
Arterial ulcers tend to have what characteristics
Very dry surrounding area that is lacking hair follicles
Very dry in general too
Symmetrical wound margins
Might see cellulitis going up the leg
Culture methods
Biopsy is the gold standard - is invasive though, usually requires local, and is expensive
Swab - most common
Bone probe
Culture swab
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
Culture methods - when would you bone probe
When suspect osteomyelitis
When probe, it breaks apart, can send a piece to culture
Best for bone is diagnostic imaging though
When would you do a culture?
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
Surrounding tissue/Peri wound area - look at
Color
Edema
Condition
Surrounding tissue/Peri wound area - Color
Darkened pigmented - may indicate damaged tissue
Redness - inflammation, cellulitis
Surrounding tissue/Peri wound area - Edema
Need to measure it
How far does it extend
Is it pitting
Surrounding tissue/Peri wound area - Condition
Dry, flaky
Macerated (wet)
Indurated (hard)
Lipodermatosclerosis (hard but with specific color, bounces back a little more too)
Surrounding tissue/Peri wound area - Symmetry
Cellulitis - usually asymmetrical surrounding
Inflammation - usually more symmetrical surrounding
Foot deformities/Pressures
Look for calluses, corns
Malformed nails
Make note of any deformities - hallux valgus, pes planus, pes cavus, hammer toes
