1350: Wound Assessment Exam 3

Card Set Information

Author:
xiongav
ID:
290138
Filename:
1350: Wound Assessment Exam 3
Updated:
2014-12-02 19:29:41
Tags:
NURS
Folders:

Description:
wound assessment
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user xiongav on FreezingBlue Flashcards. What would you like to do?


  1. What is included in the health history exam assessment regarding wounds?
    • hydration and nutrition
    • -->nutrition: protein: 1.25 - 1.5 g/kg; calories: 30-35 kcal/kg; zinc: 200mg/daily; vitamin A & C
    • mobility
    • Braden scale (pressure ulcer  risk assessment)
  2. What can you detect using your sense of smell?
    odor; may indicate infection.
  3. While inspecting the wound, what should you inspect regarding skin color?
    • hypo/hyper pigmentation
    • vitiligo (white patches)
    • cyanosis
    • erythema
    • jaundice
    • rash/lesions
    • pruritis
  4. While inspecting the wound, what should you inspect regarding appearance of the wound bed?

    Describe the appearances and intervention.
    Granulation: red, cobblestone appearance; *protect

    • Necrotic:
    • Slough: yellow tan; dead tissue (stage 3 or 4 pressure ulcer) *cleanse 
    • Eschar: black/brown, hard/soft; *debride
  5. While inspecting the wound, what should you inspect regarding drainage?

    What are the types of drainage?
    • color
    • consistency
    • odor 
    • quantity

    • serous: clear
    • sanguinous: bloody
    • serosanguinous: clear and bloody
    • purulent: pus
  6. While inspecting the wound, what should you inspect with your tactile senses (touch)?
    • pain assessment
    • skin turgor
    • edema
  7. How do you measure a wound?
    • length: head-to-toe
    • width: side to side
    • depth: measure DEEPEST area; use a q-tip and then hold it against a ruler to measure.

What would you like to do?

Home > Flashcards > Print Preview