Term
| What attributes must a wound assessment include? |
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Definition
| 1. wound attributes 2. periwound attributes 3. exudate attributes |
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Term
| Important wound history questions |
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Definition
| 1. Previous wounds (location, duration, treatment) 2. Medical history (PVD, cardiac, diabetes, neuropathies, sensory deficits) 3. Duration of present wound |
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Term
| What does a flaky, dry periwound area tell you? How does it impact your Tx? |
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Definition
| The wound is probably dry too. You want to promote moisturization. |
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Term
| What to look for in the periwound area: (5) |
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Definition
| 1. If it's flaky/dry or flexible/elastic 2. If it's moist, and the type of moisture 3. Color: if it's red, white, purple 4. Hair over digits (loss of hair = vascular probs) 5. Thickened nails 6. Edema (pitting/non) 7. Sensation 8. Callousing 9. Temp 10. Vascular response 11. Scar tissue |
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Term
| What to look for w/ scar tissue (7) |
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Definition
| 1. if it's smooth/flexible (ideal) 2. Thickness 3. Toughness (palpate) 4. Color 5. Scar abnormalities (keloid/hypertrophic) 6. Itchiness 7. Pain |
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Term
| What does pink scar tissue indicate? |
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Definition
| It's still healing; not yet mature. |
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Term
| What is the difference between a hypertrophic and a keloid scar? |
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Definition
| Hypertrophic: scar is larger than wound. Keloid: Scar tissue is significantly raised above normal tissue. |
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Term
| Wound documentation should include: (6 major) |
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Definition
| 1. Location 2. General Shape 3. Stage/depth 4. wound edges (undermining, tunneling) 5. Drainage (serous, sanguinous, color, odor, volume) 6. Wound types (neuropathic, venous, arterial, pressure) |
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Term
| Wound bed examination (7 major points) |
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Definition
| 1. Color 2. Tissue quality (granulation, necrotic, etc) 3. Consistency (wet, stringy, dry, thick, thin, clumpy) 4. Depth (measure w/ Qtip) 5. General appearance (take pic/outline tracing) 6. Size (greatest length x greatest width) 7. Tissue color (yellow, green, black, red) |
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