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Wound Evaluation
| Question | Answer |
|---|---|
| Subjective Exam (general) includes: | 1. demographics 2. employment 3. social info 4. PMH 5. current status |
| Important medication types | Anti-inflammatory, Anti-diabetic, cardiac, antibiotic |
| Subjective Exam (wound specific) includes: | 1. MOI or disease 2. date of onset 3. duration of injury/disease 4. course of events 5. past or current interventions/effects 6. Pain/paresthesia/anesthesia 7. Special questions (imaging, cultures, labs, S&S of infection, orthopnea if cardiac) |
| Serum albumin norm and importance | 3.5-5.5 longer half life :.longer index of malnutrition |
| Prealbumin norm and importance | 20-40 shorter half life :. shorter/recent index of malnutrition |
| Fasting blood glucose norm | 70-115 |
| Glycosylated hemoglobin (A1C) nrom | 4-6% |
| Hemoglobin norm | 12-16 females; 13-18 males |
| Hematocrit norm | 37-48% females; 42-52% males |
| WBC norm | 4.5-11 x 10^3 |
| Objective exam | 1. Presentation (footwear, AD, position, functional mob) 2. Presence of dressings (integrity, appropriateness) 3. Tests & Measures (pending wound type--sensory, vascular, girth, ROM, etc) |
| Depth | deepest aspect of wound to horizontal plane of intact wound edge |
| Tunnel | linear channel extending beyond wound base; may have entrance and exit points |
| Sinus tract | dead end channel |
| undermining | wound edge erosion where fascia separates from deeper tissue around wound edge |
| Fistula | vertical or oblique channel originating from a wound that penetrates a body cavity |
| Serous drainage | clear, watery drainage, found in inflammation and proliferation phases |
| sanguinous | red, bloody drainage due to damaged vessels |
| serosanguinous | pink/reddish, water drainage; found in inflammation and proliferation phases |
| purulent/pus | yellow, green, tan drainage that may be cloudy, watery or viscous; may have odor |
| Sign of staph | creamy, yellow pus |
| sign of proteus | fishy odor |
| sign of pseudomonas | green or blue-green, fruity odor |
| Pus: yes or no? anaerobes | NO |
| Pus: yes or no? streptococcal cellulites | NO |
| Pus: yes or no? gas gangrene | NO |
| Pus: yes or no? infected burns | NO |
| local S&S of infection | erythema palpable heat odor edema/induration |
| Signs of sepsis | unexplained fever tachycardia hypotension AMS chills N&V |
| Epithelium | translucent layer covering previous granulation |
| granulation | pink/red, granular looking |
| slough/fibrin | soft, moist, dead fibrous tissue; may be tan/white/brown/green; may be stringy, loose, or adherent to wound bed |
| eschar | brown or black necrotic tissue; may be adhered or separated from wound edge; may be hard, soft, or boggy |
| exposed structure | Bone (white or light grey) tendon/ligament (white or light yellow) Adipose (yellow, globular, waxy texture) Muscle (bright red with visible striations) vessels (ropelike; arteries firm, veins thin and compressible) |
| Complete epithelialization | wound bed is covered with epithelium; closed |
| epithelializing | epidermal cells advancing from wound edges and/or epithelial appendages |
| epibole | curled wound edge due to contact inhibition of epithelial cells |
| callus | thick, hyperkeratotic tissue |
| indisctinct/diffuse edges | cannot distinguish boundaries of wound edges from periwound |
| fibrotic, scarred | immediate wound edge/periwound skin is scarred |
| ecchymosis/hemorrhagic | blue, purple, black tissue from disrupted blood vessels |
| excoriated | tissue injury from mechanical, chemical, or thermal injury |
| indurated | tissue hardened from edema, inflammation, or granulation |
| inflamed | tissue response to injury: redness, warmth, edema, pain, loss of function |
| macerated | tissue damage or softening from too much moisture |
Created by:
ktay13
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