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wound assessment
WOCN program
| Question | Answer |
|---|---|
| list 8 wound assessment parameters | location, size, wound edges, wound bed, periwound skin, exudate, odor, signs of infection, extent of tissue loss, |
| describe three methods for wound measurement | linear, (length, width and depth, tunneling, undermining) planimetry |
| identify three wound classification systems | Burns (degrees) pressure ulcers (NUPUAP) skin tears, radiation dermatitis |
| discuss tools for documentation and evaluation of healing | PUSH, BWAT/PSST, measurements for ongoing assessment and comparison |
| distinguish between viable and nonviable tissue | epithelial or granulating tissue, or slough, necrotic, or stagnant tissue (nongranulating) |
| describe how to measure length, width and depth of a wound | Head to toe, Side to side, depth by using swab and measuring the length that does in. Uses clock face to describe location. |
| how should the periwound be assessed? | color, moisture, texture, presence or absence of injury |
| describe how to measure a wound using a two dimensional measurement | Length and width |
| what is the difference between undermining and tunneling in a wound | Undermining is broader, like from 12oclock to 3 o'clock tunneling is narrow she heads in one direction |
| what are the critical parameters to include when assessing | wound etiology, duration of wound, cofactors that impede healing |
| identify the wound evaluation process | wound focused physical assessment-all wound assessment parameters plus cofactors |
| discuss the controversy regarding photography of wounds | HIPPA, consent, quality of phto, ability to be altered, blurred or poor quality photo could be interpreted as poor wound care |
| identify 10 wound assessment parameters | Location, partial or full thickness loss, tissue in wound base, %of slough or necrotic tiss., dimensions, undermining, exudate, odor, wound edges, periwound skin,wound pain |
| name four classification systems based on etiology | pressure ulcer staging, (I-IV) skin tear (Payne Martin), venous ulcers (CEAP), and diabetic neuropathic wounds (Wagner Grade) |
| describe health granulation tissue | Red, moist, cobblestone appearance |
| a wound assessed to have smooth, red tissue would be documented as _____ | Clean, non granulating |
| an overproduction of granulation tissue is documented as _____ | Hypergranulation |
| premature closure of wound edges that are thickened and rolled down is called __________ | Epibole |
| identify periwound conditions of a pressure ulcer | hyperemia, edema, induration, discoloration |
| name one wound assessment tool | Bates - Jensen wound assessment tool (PSST) PUSH / NUPUAP |
| what is the name of the comprehensive assessment tool for Medicare payment to home care agencies? | OASIS |
| How would extent of tissue loss be described | Classification, partial or full thickness , or stage |
| How would a wound base be described | Color -red,, tan, black, pink, white, etc. viable (red, moist, = granulation pink and dry=epithelial tissue), nonviable ( slough or eschar) |
| How would exudate be described | Quantity- (light, moderate, heavy) or in ml's. type – clear, Sanguineous, serosanguineous, purulent |
| List cofactors to include in assessment | Tissue oxygenation, bacterial load, circulation, nutrition, glycemic control, comorbidities |
| How would periwound skin be described | Color, texture, temperature, integrity,presence or absence of lesions |
| wound assessment cofactors | nutrition, underlying disease, oxygenation, glycemic control, bacterial load, circulation |
| how is the extent and significance of bioburdern conveyed | contamination, colonization, critical colonization, biofilm, infection |
| wound bed descriptions | necrotic, nonviable, devitalized, eschar, slough, scab (not eschar) gran. tissue, clean nongranulating, epithelial |
| periwound features of venous insufficiency | edema, brawny discoloration, hemosiderin staining, lipoderatosclerosis, dermatitis, scaling, weeping |
| periwound features of arterial | pale color, cool, dependent rubor, absent hair, xerosis |
| periwound features of infection | erythema, pain heat, swelling, induration |
| periwound features of pressure | hyperemia, edema, induration, discoloration |
| periwound features of peripheral neuropathy | insensate, edema, cellulitis, erythema, induration |
| periwound features of pyoderma gangrenosum | ragged and boggy borders, elevated borders, dusky red or purple, halo of edema |
| periwound features of vasculitis | palpable, nonblanchable purpura, may have petechiae, nodules and vesicles may be present |
| periwound features of calciphylaxis | dusky, purple, palpable nodules progress to necrosis and ulceration, associated with renal disease, may include mottled, reticulated patches, plaques with focal central necrosis |
| periwound features of candidiasis | pustular or macular-papular rash, erythematous satellite lesions |
| parameters for skin assessment | color, turgor, texture, temperature, lesions, moisture |
Created by:
Beth Perry
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