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wound assessment

WOCN program

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