1350: Wound Assessment Exam 3

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  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.

Card Set Information

Author:
xiongav
ID:
290138
Filename:
1350: Wound Assessment Exam 3
Updated:
2014-12-03 00:29:41
Tags:
NURS
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Description:
wound assessment
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