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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
- 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)
- ordor (irrigate it first)
- periwound tissue condition
- tissue turgor
- temperature in and around wound
- PUSH tool value (for pressure ulcers only)
General pt assessment
- good chart review is impt
- vital signs,
- cognitive status (AO x4)
- pulse strength
- level of sensation
- contractures or deformaties
- functional strength of pt
- bed mobility
- braden scale (for developing a pressure ulcer)
how do you measure the size of the wound
- in cm
- measure greatest length and greatest width
when measuring wound depth, do you include the necrotic tissue layer
no, either note the presence or debride then measure
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
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
what is black necrotic tissue?
- dehydrated dead skin
- called eschor
what is yellow necrotic tissue?
- hydrated dead tissue
- called slough
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
what does a circular wound typically indicate?
a neuropathical wound
what does an irregular/jagged wound usually indicate?
venous stasis wound
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)
how could you describe the odor of a wound?
How could you describe the periwound tissue?
red, hot, soft, hard ("induration"), amt of drainage, staining (hemosiderin deposits)
indications of poor circulation
- lack of hair growth
- shiny skin
- thick and more yellow nails
what are the different grades of edema?
- +1: 0" - 1/4"
- +2: 1/4" - 1/2"
- +3: 1/2" - 1"
- +4: > 1"
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
How to calculate BMI?
- wt / ht2
- convert lbs to kg (lbs/2.2)
- convert inches to m (in * 2.54 and move decimal pt)
what are the BMI ranges?
- below 18.5: underweight
- 18.6 - 24.9: normal
- 25-29.9: overweight
- > 30: obese
How to test sensation?
- monofilament test: 10g of force to bend it
- see if pt can feel it
- usually tested in weight bearing areas
What would you like to do?
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