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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
- Braden scale (pressure ulcer risk assessment)
What can you detect using your sense of smell?
odor; may indicate infection.
While inspecting the wound, what should you inspect regarding skin color?
- hypo/hyper pigmentation
- vitiligo (white patches)
While inspecting the wound, what should you inspect regarding appearance of the wound bed?
Describe the appearances and intervention.
Granulation: red, cobblestone appearance; *protect
- Slough: yellow tan; dead tissue (stage 3 or 4 pressure ulcer) *cleanse
- Eschar: black/brown, hard/soft; *debride
While inspecting the wound, what should you inspect regarding drainage?
What are the types of drainage?
- serous: clear
- sanguinous: bloody
- serosanguinous: clear and bloody
- purulent: pus
While inspecting the wound, what should you inspect with your tactile senses (touch)?
- pain assessment
- skin turgor
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.