577: Exam 1: Wound Evaluation

Front 1

what must be done in order to appropriately treat any wound

Back 1

must determine underlying cause - and address it.... if you don't address/correct it, no treatment will be effective

Front 2

where are pressure ulcers typically located

Back 2

over boney prominences

Front 3

pressure ulcers are caused by prolonged pressure leading to

Back 3

ischemia and eventually cell death

Front 4

how are pressure ulcers classified

Back 4

by "stages" to describe the amount ot tissue destruction..... may progress in stages but CANNOT back-stage

Front 5

what are the contributing factors to pressure ulcers (8)

Back 5

1) impaired circulation
2) decreased mobility
3) predisposing illness
4) diminshed mental capacity
5) incontience
6) poor nutrition/dehydration
7) past hx of pressure ulcers
8) poorly fitting splints/braces

Front 6

what are the 6 categories for "staging a pressure ulcer"

Back 6

1) suspected deep tissue injury
2) stage 1
3) stage 2
4) stage 3
5) stage 4
6) unstageable

Front 7

what characterizes a suspected deep tissue injury

Back 7

- purple or maroon localized area of discolored intact skin
- or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (likely to become open wounds)

Front 8

what characterizes a stage 1 pressure ulcer

Back 8

- intact skin with non-blanchable redness of a localized area usually over a bony prominence
- darkly pigmented skin may not have visible blanching

Front 9

what characterizes a stage 2 pressure ulcer

Back 9

- partial thickness loss of dermis
- presenting as a shallow open ulcer
- red/pink wound bed
- WITHOUT slough
- may also present as an intact or open/ruptured serum -filled blister
- typically painful

Front 10

what characterizes a stage 3 pressure ulcer

Back 10

- full thickness tissue loss
- subQ fat may be visible but no bone, tendon, muscle are exposed
- slough may be present but doesn't obscure the depth of the tissue loss
- may include undermining and tunneling

Front 11

what characterizes a stage 4 pressure ulcer

Back 11

- full thickness tissue loss
- exposed bone, tendon or muscle
- slough or schar may be present on some part of wound bed
- often include undermining and tunneling

Front 12

which stages of a pressure ulcer could have slough

Back 12

only 3 and 4

Front 13

which stages of a pressure ulcer would be partial thickness loss of dermis

Back 13

stage 2

Front 14

which stages of a pressure ulcer still has intact skin

Back 14

stage 1

Front 15

which stages of a pressure ulcer presents with exposed bone, tendon or muscle

Back 15

stage 4

Front 16

which stages of a pressure ulcer would be fulll thickness tissue loss

Back 16

stages 3 and 4 and also full thickness

Front 17

which stages of a pressure ulcer are typically painful

Back 17

stage 2 becasue only partial thickness.... so intact nerve endings to cause pain

Front 18

what characterizes an unstageable pressure ulcer

Back 18

- full thickness tissue loss
- base of ulcer covered by slough and/or exchar in the wound bed

Front 19

if a pressure ulcer is unstageable, how do you go about staging it?

Back 19

must debrind all the slough away before you can stage the wound

Front 20

what colors could slough present as

Back 20

- yellow
- tan
- gray
- green
- brown

Front 21

what colors could eschar present as

Back 21

- tan
- black
- brown

Front 22

vascular wounds can be described as ____ or _____

Back 22

partial or full thickness wounds

Front 23

what causes an arterial wound

Back 23

lack of adequate perfusion leads to ischemic skin changes

Front 24

where are arterial wounds typically found

Back 24

toes, feet, distal third of leg

Front 25

how would an arterial wound present

Back 25

- very little drainage
- patient increased pain with leg elevation

Front 26

what causes a venous wound

Back 26

incompetent valves lead to a fluid overload in the lower extremitied --> edema

Front 27

where are venous wounds typically found

Back 27

distal, middle third of leg

Front 28

how would a venous wound present

Back 28

- heavy amounts of drainage
- elevation helps relieve symptoms

Front 29

differentiate venous from arterial wounds based on pain and drainage

Back 29

arterial = little drainage; elevation increases pain

venous = heavy drainage; elevation decreases symptoms

Front 30

what are neuropathic wounds

Back 30

"diabetic ulcers"
- various neuropathies (sensory, motor, autonomic) contribute to changes in the foot which can lead to ulceration

Front 31

Differential Diagnosis:
arterial vs. venous vs. neuropathic wounds
--> Cause

Back 31

Arterial: arteriosclerosis
Venous: venous insufficiency
Neuropathic: diabetes

Front 32

Differential Diagnosis:
arterial vs. venous vs. neuropathic wounds
--> pain

Back 32

Arterial: severe
Venous: moderate
Neuropathic: none

Front 33

Differential Diagnosis:
arterial vs. venous vs. neuropathic wounds
--> location

Back 33

Arterial: toes, feet, lower third of leg

Venous: proximal to medial malleolus

Neuropathic: plantar foot

Front 34

How would an arterial wound appear

Back 34

- defined borders
- pale base
- little drainage

Front 35

how would a venous wound appear

Back 35

- irregular borders
- pink base
- heavy drainage
- hemosiderin staining

Front 36

how would a neuropathic wound appear

Back 36

- pale pink base
- moderate drainage
- callous

Front 37

what does traumatic wound describe

Back 37

wide variety of causes:
- shear
- GSW
- burns
- skin breakdown due to incontinence

Front 38

what are surgical wounds

Back 38

man-made wounds due to surgical procedure, debridement, incison and drainage

Front 39

what are the components of a wound evaluation (13)

Back 39

1) location
2) measurements
3) wound bed (assess after cleaning)
4) wound edges
5) drainage
6) periwound skin
7) pain
8) vascular evaluation
9) Edema
10) sensation
11) strength and motion
12) goals
13) wound re-evaluation

Front 40

how do you describe the lcoation of a wound

Back 40

anatomically and specifically

Front 41

the location of a wound helps to determine what two things

Back 41

1) determine the type of wound
2) determine the appropriate positioning and support surfaces/devices

Front 42

how do you record the measurements of a wound

Back 42

L X W X D
= longest aspect of wound x widest aspect of visible wound x deepest part of wound

Front 43

what is undermining

Back 43

wound edges are seperated from the underlying base

Front 44

how do you describe undermining

Back 44

using the clock method

Front 45

what is tunneling

Back 45

tunnel of tissue destruction from the wound edge

Front 46

how do you describe tunneling

Back 46

measured and described like undermining

Front 47

what color is healthy tissue

Back 47

pink or red

Front 48

what color is necrotic tissue

Back 48

yellow, tan, black

Front 49

what two things are used to describe the wound bed

Back 49

color and visible structures (bone, tendon, etc)

Front 50

why do we want to protect visible structuers in a wound bed

Back 50

to maintain function and prevent infection

Front 51

what is the benefit of a thorough asssessment of wound edge

Back 51

allow more timely intervention to address barriers to healing

Front 52

what are the 5 main things you look for when assessing the wound edge

Back 52

- maceration
- epibole
- callous
- fibrosis
- hypergranulation

Front 53

what are the three components of describing drainage

Back 53

- type
- amount
- odor

Front 54

what are the types of drainage

Back 54

- serous (clear)
- serosanguinous (blood-tinged)
- sanguinous (bloody)
- purulent (pus)

Front 55

drainage amount can be....

Back 55

- none
- light
- moderate
- heavy

Front 56

what odors could a wound have

Back 56

- sweet
- ammonia-like
- foul

Front 57

a pseudomosa would have what type of smell

Back 57

sweet

Front 58

what does odor indicate

Back 58

likely infection

Front 59

when assessing the periwound skin you are assessing for the presence/absence of:

Back 59

hair, callous, edema, new epithelial growth

Front 60

how would you describe hydration of the peridound

Back 60

maceration vs. dry skin

Front 61

how would you describe the periwound skin when assessing skin color

Back 61

erythema, eccymosis, ischemia, hemosiderin staining

Front 62

what is induration

Back 62

"hard edema" --- needs to be monitored closely and treated

Front 63

what are the components of the wound evaluation for pain

Back 63

- pt objectively rates pain
- distinguish between wound pain and other types of pain
- establish goals related to pain modulation

Front 64

what do you include in your vascuar assessment

Back 64

- skin temp and pulses
- venous assessment
- arterial assessment

Front 65

what are the tests that can be used for a venous assessment

Back 65

- percussion test
- trendelenberg test
- cuff test
- ABI >0.8= compression allowed

Front 66

what are the tests that can be used for an arterial assessment

Back 66

- ABI
- rubor of dependency
- venous filling time
- claudication tie
- capillary refill test
- lower extremity doppler

Front 67

why do we objectively measure edema

Back 67

to track progress

Front 68

how do we take girth measurements

Back 68

using landmarks for consistency and measured at various locations
- document well and compare to ther side

Front 69

when is a sensation assessment extremely important

Back 69

in patients with neuropathy, CVA, SCI

Front 70

the protective sensation is still intact it a patient can detect a monofiliment that is _____

Back 70

5.07

Front 71

Goals for a wound evaluation must be ____ and _____

Back 71

time-oriented and measurable

Front 72

when should you re-evaluate a wound

Back 72

weekly and prn

Front 73

what would you like to see when re-evaluating a wound

Back 73

signs of healing in 2 weeks, otherwise change treatment

Front 74

what is the expected progress to healing

Back 74

hemostasis --> inflammation --> proliferation --> remodeling

Front 75

wounds must be free from ______ in order to heal

Back 75

free from necrotic tissue