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Initial info to gather about the wound itself
- type of onset: sudden or gradual
- most recent medical treatment
- general tx path applied
- location
- size
- depth
- if any tunneling or sinus tracking
- if any undermining
- % of black necrotic tissue
- % of yellow necrotic tissue
- % of healthy red granulated tissue
- % of pale pink tissue
- shape of wound (circular vs irregular)
- drainage
- color
- ordor (irrigate it first)
- periwound tissue condition
- tissue turgor
- temperature in and around wound
- PUSH tool value (for pressure ulcers only)
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General pt assessment
- good chart review is impt
- vital signs,
- cognitive status (AO x4)
- circulation
- edema
- pulse strength
- BMI
- level of sensation
- contractures or deformaties
- functional strength of pt
- bed mobility
- mobility
- braden scale (for developing a pressure ulcer)
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how do you measure the size of the wound
- in cm
- measure greatest length and greatest width
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when measuring wound depth, do you include the necrotic tissue layer
no, either note the presence or debride then measure
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what is tunneling or sinus tracking
- hallow passageways that form at the bottom of the wound and can go into other areas of the body
- would note the clock location if any exist
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what is undermining of a wound?
- when the subcutaneous tissue does not regenerate as quickly as cutaneous
- creates a 'dead space' under the top layer
- can lead to epiboly where the edges start to roll under
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what is black necrotic tissue?
- dehydrated dead skin
- called eschor
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what is yellow necrotic tissue?
- hydrated dead tissue
- called slough
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why is it bad if the skin within a wound is pale pink?
it means the wound could be dry or the person has poor circulation to that area
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what does a circular wound typically indicate?
a neuropathical wound
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what does an irregular/jagged wound usually indicate?
venous stasis wound
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what variables do you use to describe a wounds drainage?
- the amoung: no, moderate, scant, little, copious
- the color: serous (clear), sanguinous (bloody), purulent (pus/whitish)
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how could you describe the odor of a wound?
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How could you describe the periwound tissue?
red, hot, soft, hard ("induration"), amt of drainage, staining (hemosiderin deposits)
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indications of poor circulation
- lack of hair growth
- shiny skin
- thick and more yellow nails
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what are the different grades of edema?
- non-pitting
- +1: 0" - 1/4"
- +2: 1/4" - 1/2"
- +3: 1/2" - 1"
- +4: > 1"
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what are the different grades of pulses
- +4: abnormally strong, could indicate aneurysim
- +3: normal
- +2: weak pulse
- +1: barely perceptable
- 0: No palpable pulse
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How to calculate BMI?
- wt / ht2
- convert lbs to kg (lbs/2.2)
- convert inches to m (in * 2.54 and move decimal pt)
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what are the BMI ranges?
- below 18.5: underweight
- 18.6 - 24.9: normal
- 25-29.9: overweight
- > 30: obese
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How to test sensation?
- monofilament test: 10g of force to bend it
- see if pt can feel it
- usually tested in weight bearing areas
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