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Wound Assessment
N/A
119
Health Care
06/17/2013

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Cards

Term
Integumentary Scan - what to look for (categories) (6)
Definition
color/texture
skin rxns/responses
nails
lesions
skin integrity/sensation
risk assessment
Term
Color/Texture - look fors (4)
Definition
pallor/pale
jaundice
cyanosis
gangrene
Term
Skin rxn/responses: examples (3)
Definition
lymphangitis
phlebitis
Raynaud's
Term
green nails signify...
Definition
pseudomonas infection
Term
black nail bed signifies...
Definition
melanoma
Term
60 second foot screen: 0-15s
Definition
examine callus, color, toenails, structure
Term
60 second foot screen: 15-30s
Definition
pulses, ROM
Term
60 second foot screen: 30-60s
Definition
sensory intactness
Term
60 second foot screen: Q to ask
Definition
feet numb, tingling, burning, crawling?
Term
Integumentary tests/measures (6)
Definition
wound characteristics
pressure risk assessment
vascular testing
neuropathic testing
periwound tissue
infection
Term
Risk assessment: primary scale used
Definition
Braden/Norton scale

(used to plan prevention, Rx; Norton=peds)
Term
Diabetic Ulcer Risk: incr risk c: (3...)
Definition
monofilament insensation
hx of amputation
hx of ulcer
...
Term
Vv ulcers: triggers (4...)
Definition
cellulitis
direct injury
dermatitis
rapid edema
Term
Aa ulcers: risk factors
Definition
= risk factors for CAD
Term
Phases of tissue healing (3)
Definition
inflammation
proliferation
maturation/remodeling
Term
Tissue healing: inflammation
steps involved
Definition
coagulation
aggregation of cells (lymphocytes, platelets, etc)
Term
Tissue healing: proliferation
steps involved
Definition
epithelialization
fibroplasia
Term
Tissue healing: maturation/remodeling
steps involved
Definition
scar tissue
wound closure
COLLAGEN remodeling
Term
Chronic wounds: which healing stage is prolonged?
Definition
prolonged inflammatory stage
(inhibits proliferative stage)
Term
Chronic wounds: causes (5)
Definition
repetitive trauma
local ischemia
necrotic tissue
heavy bacterial burden
tissue breakdown
Term
MMPs (matrix metalloproteases)
Definition
pro-inflammatory substances; cause wounds to stay in inflammatory state
break down developing collagen matrix; inhibits growth factors
Term
TIMPs
Definition
anti-inflammatory subtances (in the body)
antagonists to MMPs
Term
Subjective exam: questions (20)
Definition
when/how wound began
precipitating event
Rx
S/Sx
pain
improving/regressing
comorbs
meds
allergies
nutrition
other substances
activity level
fxnl level
ADs
shoes
family hx
caregiver/family support
PMHx
previous wounds/infections
pt concerns/goals
Term
Cardiopulmonary: effect on wounds/integument
Definition
O2 delivery/blood supply
Term
Musculoskeletal: effect on wounds/integument
Definition
mm pump
ROM (e.g. affects gait)
Term
Neuromuscular: effect on wounds/integument
Definition
posture
abnormal tone
ANS dysfxn
Term
Wound exam: acronym
Definition
A MEASURES
Term
Wound exam: A MEASURES - A1
Definition
anatomic location
Term
Wound exam: A MEASURES - M
Definition
measures (LxWxD)

*most frequently left out of pt documentation)
Term
Wound exam: A MEASURES - E
Definition
edge, surrounding skin
Term
Wound exam: A MEASURES - A2
Definition
appearance x3
Term
Wound exam: A MEASURES - S1
Definition
suffering/pain
Term
Wound exam: A MEASURES - U
Definition
undermining
Term
Wound exam: A MEASURES - R
Definition
re-eval (onset, duration, previous Rx)
Term
Wound exam: A MEASURES - E
Definition
exudate (appearance, amt, odor)
Term
Wound exam: A MEASURES - S2
Definition
sensation x5
Term
Wound exam: edges - irregular
Definition
vv ulcers
Term
Wound exam: edges - even
Definition
aa ulcers
Term
Wound exam: edges - rolled/closed
Definition
halted healing
Term
Wound exam: edges - hyperkeratosis
Definition
neuropathic ulcers
Term
Wound exam: edges - macerated
Definition
too much moisture
Term
Wound exam: edges - inflamed
Definition
infection
Term
Wound exam: edges - epithelialization
Definition
normal; healthy healing
Term
Wound exam: surrounding skin - erythema
Definition
normal or abnormal
Term
Wound exam: surrounding skin - maceration >>
Definition
infections, skin tears
Term
Wound exam: surrounding skin - purple ulcer
Definition
deep tissue injury
Term
Wound exam: surrounding skin - hemosiderin staining
Definition
vv insufficiency
Term
pressure ulcers: Stage I
Definition
skin intact, unblanchable
Term
pressure ulcers: Stage II
Definition
partial thickness loss
no slough
Term
pressure ulcers: Stage III
Definition
full thickness loss
NO bone/tendon/mm visibile
Term
pressure ulcers: Stage IV
Definition
full thickness loss
bone/tendon/mm visible
Term
pressure ulcers: Unstagable
Definition
covered c eschar
Term
CEAP classification of wounds:
Definition
Clinical severity
Etiology
Anatomy
Pathophysiology
Term
Appearance of bone: color - healthy v infected
Definition
healthy: tan
infected: dark, brown
Term
Infection (superficial) acronym
Definition
NERDS
Term
Infection (deep) acronym
Definition
STONES
Term
Infection (superficial) acronym: N
Definition
nonhealing wound (.87)
Term
Infection (superficial) acronym: E
Definition
exudative wound (.74-.78)
Term
Infection (superficial) acronym: R
Definition
red & bleeding (.76)
Term
Infection (superficial) acronym: D
Definition
debris
Term
Infection (superficial) acronym: S
Definition
smell
Term
Infection (deep) acronym: S1
Definition
size (bigger)
Term
Infection (deep) acronym: T
Definition
temperature (raised c systemic issue)
Term
Infection (deep) acronym: O
Definition
Os (osteomyelitis; very likely if probe reaches bone)
Term
Infection (deep) acronym: N
Definition
new breakdown (100%)
Term
Infection (deep) acronym: E (3)
Definition
edema (.93)
exudate
erythema
Term
Infection (deep) acronym: S2
Definition
smell (.85)
Term
Infection: smell - sweet
Definition
pseudomonas
Term
Infection: smell - putrid
Definition
tissue breakdown
Term
highest predictive value for development of infection =
Definition
change in pain
Term
Exudate: descriptors to include (3)
Definition
appearance
amount
odor
Term
Infection: smell - ammonia
Definition
proteus
Term
Infection: smell - musky
Definition
malignancy
Term
Appearance x3
Definition
extent of damage
type of tissue
infection
Term
Sensation x5
Definition
lt touch
vibration
temp
proprio
pressure
Term
Vv ulcer: temp
Definition
ambient
Term
Vv ulcer: color
Definition
hyperpigmented (hemosideriosis)
Term
Vv ulcer: skin
Definition
pitting edema
Term
Vv ulcer: hair/nail
Definition
normal
Term
Vv ulcer: capillary refill
Definition
<3 sec
Term
Vv ulcer: ulcer appearance
Definition
shallow, moist
Term
aa ulcer: temp
Definition
cool/cold
Term
aa ulcer: color
Definition
pale/
dependent rubor
Term
aa ulcer: skin
Definition
thin/shiny
Term
aa ulcer: hair/nail
Definition
hair loss,
thick nails
Term
aa ulcer: capillary refill
Definition
>3 sec
Term
aa ulcer: ulcer appearance
Definition
"punched out" appearance
Term
Vv ulcers: Rx the cause (6)
Definition
R/O aa disease
check vascular flow
ankle jt mobility
vv reflux
compression
meds
Term
Vv ulcers: suggested meds
Definition
Pentoxifylline
Term
Pt centered concerns (3)
Definition
adherence
lifestyle changes
pain
Term
Aa ulcers: Rx the cause (6)
Definition
vasulcar diagnositcs
endovascular intervention
sx revascularization
pharmacotherapeutics
amputation
adjunct mgmt
Term
Sx wounds: Rx (3)
Definition
mgmt of disease process
nutritional support
mgmt of fluid/electrolytes
Term
Neuropathic ulcers: Rx (4)
Definition
aa vascular assessment
glycemic control
offloading
sx
Term
Good ability to heal: palpable pulse
Definition
at 80 mmHg cuff pressure
Term
Good ability to heal: ABI
Definition
>0.5
Term
Good ability to heal: transQ O2 tension
Definition
>30mmHg
Term
Good ability to heal: toe pressure
Definition
>55mmHg
Term
Factors that affect healing: acronym
Definition
DEAD

(drugs, edema, anemia, disease)
Term
Wound appearance+Rx acronym
Definition
DIME
Term
Rx for necrotic wound (DIME)
Definition
Debridement
Term
Rx for infected wound (DIME)
Definition
infection control
Term
Rx for draining/granular wound (DIME)
Definition
moisture balance
Term
Rx for non-healing wound (DIME)
Definition
edge
Term
Types of debridement (5)
Definition
sharp
autolytic
mechanical
enzymatic
biologic
Term
Types of debridement - fastest
Definition
surgical
Term
Types of debridement - most selective
Definition
enzymatic
Term
Types of debridement - least painful
Definition
autolytic
Term
Types of debridement - best for exudate
Definition
surgical
Term
Types of debridement - best for infection
Definition
surgical
Term
Types of debridement - lowest cost
Definition
autolytic
Term
DIME - infection control (4)
Definition
antibiotics
cytotoxic solutions
dressings
topical agents
Term
DIME - moisture balance (3)
Definition
control & absorb
protect periwound
infection?
Term
DIME - edge (4)
Definition
platelet-derived growth factor (PDGF)
skin substitutes
negative pressure therapy (VAC)
physical agents
Term
Dressings: 3 major classes
Definition
uninfected
infected
alginate
Term
Dressing choice for uninfected, dry wound
Definition
hydrogel
Term
Dressing choice for uninfected, min exudate wound (3)
Definition
film
thin foam
thin hydrocolloid
Term
Dressing choice for uninfected, mod exudate wound (2)
Definition
foam
hydrocolloid c alginate
Term
Dressing choice for uninfected, max exudate wound (3)
Definition
foam
hydrocolloid c alginate
alginate c gauze
Term
Dressing choice for infected wound
Definition
nonocclusive