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MS2EXAM1
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Wound Care – Assessment

Wound Care – Assessment

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Study Tools
Outline
Transcript
Additional Lessons

Study Tools For Wound Care – Assessment

Pressure Ulcer Staging (Cheatsheet)
Pressure Ulcer Staging (Image)
Common Pressure Ulcer Sites (Image)
Stage Four Pressure Ulcer (Image)
Wound Vac Therapy (Image)
Diabetic Foot Ulcer (Image)
Hydrogel Dressing (Image)
Rolled Gauze (Image)
Hydrocolloid Dressing (Image)
Types of Dressings (Image)
Types of Wound Healing (Picmonic)
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Outline

Overview

  1. Purpose
    1. Assessing wound characteristics is the only way to know if healing is occurring

Nursing Points

General

  1. Supplies
    1. Clean gloves
    2. Measuring tape
    3. Cotton-tipped applicators x 2-3

Assessment

  1. Wound bed color
    1. Black – represents full-thickness tissue death
    2. Yellow – represents death of muscle tissue and subcutaneous fat
      1. May be slough
    3. Red  – a red wound bed typically means good vasculature and the wound is healing
      1. Exception – 1st degree burns
    4. Green – gangrenous / infected
  2. Wound edges
    1. Approximated – wound edges touching
      1. May be approximated with staples, suture, or glue
    2. Unapproximated – wound edges aren’t touching
    3. Rolled – the epidermis has rolled under towards the wound bed
  3. Wound bed characteristics
    1. Eschar – black or yellow – may be tough or leathery – reflects necrosis or dead tissue
    2. Granulation  – pink or red and bumpy – means tissue is growing
    3. Moist/dry – depends on drainage, moist is best in open wounds as long as no infection is present.
    4. Tunnelling – there are holes in the wound bed that extend deeper than the main wound
    5. Undermining – the wound bed extends beyond/underneath the wound edges (it is wider than the opening suggests)
  4. Wound drainage
    1. Serous – clear yellow
    2. Serosanguineous – yellow/pink-ish
    3. Sanguineous – bloody
    4. Purulent – white/yellow pus

Nursing Concepts

  1. Steps and Nursing Considerations
    1. Review wound care orders
    2. Explain procedure to patient
    3. Perform hand hygiene
    4. Don clean gloves
    5. Raise bed to comfortable working height.
    6. Remove existing dressing and discard in appropriate waste container
    7. Inspect wound:
      1. Wound bed color
      2. Wound edges
      3. Wound bed characteristics
      4. Wound drainage
    8. Measure wound:
      1. Using tape measurer – measure the following:
        1. Length – patient’s head to toe
        2. Width – patient’s side to side
      2. Using a sterile cotton-tipped applicator, determine the depth at the deepest portion
        1. Mark with your finger, then measure with tape
      3. Using a new sterile cotton-tipped applicator for each location – measure depth of any tunnelling or undermining
    9. Discard used supplies
    10. Remove gloves, perform hand hygiene
    11. At this point, you can move on to wound care if applicable – see Wound Care – Dressing Change lesson
    12. Document your findings.

Patient Education

  1. Let the patient know whether their wound seems like it’s healing – compare to previous assessment
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Transcript

In this video, we’re going to look at the first step when you’re performing wound care, and that is assessing the wound itself.

In order to do that, the first thing you will need to do is remove the existing dressing. This can be done with clean gloves, but if you need to get deep in and remove packing, use sterile forceps or sterile gloves.

Now that the wound is exposed, you’re going to assess it. First you want to look at the color and characteristics of the wound bed – is it red, are there streaks of yellow, is it black or green? Is it moist, is it dry and leathery? Those are all going to tell you a lot about what’s going on.

In this case, the wound bed is red and bumpy, which tells us there’s some granulation tissue – which means it’s beginning to heal.

Now you want to look at drainage and the edges of the wound. In this case, they are unapproximated, but straight. And there is no drainage. Most of the time I look at the old dressing for the drainage characteristics.
Now it’s time to measure the wound. Take your tape measurer and, holding it above the wound, measure from the patient’s head to toe – that’s your length.

Then measure from the patient’s left to right, that’s your width.

Now we want to measure depth, but we don’t want to just stick this tape measurer in the wound. So, instead, we’re going to get this sterile cotton-tipped applicator – stick it down in the wound bed and then mark the depth with your finger.
Now you can measure that on the tape measurer to get the depth.

If you have any tunnelling or undermining, you want to measure each area with a fresh sterile cotton-tipped applicator and document that.

Now that you’ve taken all of your assessment information, you can move on to the dressing change. If you need to, pause to write down your findings so you don’t forget them when you document later.

Make sure you check out the Dressing Change lesson to see how to perform a sterile dressing change.

Now, go out and be your best selves today. And, as always, happy nursing!

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MS2EXAM1

Concepts Covered:

  • Circulatory System
  • Emergency Care of the Cardiac Patient
  • Cardiac Disorders
  • Medication Administration
  • Central Nervous System Disorders – Brain
  • Shock
  • Shock
  • Urinary System
  • Adult
  • Respiratory Emergencies
  • Cardiovascular Disorders
  • Postpartum Complications
  • Emergency Care of the Neurological Patient
  • Neurological Emergencies
  • Emergency Care of the Respiratory Patient
  • Pregnancy Risks
  • Vascular Disorders
  • Noninfectious Respiratory Disorder
  • Respiratory System
  • Cardiovascular
  • Endocrine and Metabolic Disorders
  • Hematologic Disorders
  • Disorders of the Adrenal Gland
  • Neurologic and Cognitive Disorders
  • Upper GI Disorders
  • Lower GI Disorders
  • Nervous System
  • Labor Complications
  • Liver & Gallbladder Disorders
  • Oncology Disorders
  • Substance Abuse Disorders
  • Renal and Urinary Disorders
  • Integumentary Disorders
  • Renal Disorders
  • Gastrointestinal Disorders
  • Acute & Chronic Renal Disorders
  • Respiratory Disorders
  • Disorders of Pancreas
  • Disorders of the Posterior Pituitary Gland
  • Endocrine
  • Gastrointestinal
  • Renal
  • Endocrine System
  • Disorders of the Thyroid & Parathyroid Glands
  • Integumentary Disorders
  • Musculoskeletal Trauma
  • Urinary Disorders

Study Plan Lessons

EKG Basics – Live Tutoring Archive
Dysrhythmia Emergencies
Electrical Activity in the Heart
EKG (ECG) Waveforms
The EKG (ECG) Graph
Normal Sinus Rhythm
Sinus Tachycardia
Sinus Bradycardia
Supraventricular Tachycardia (SVT)
Atrial Flutter
Atrial Fibrillation (A Fib)
Premature Ventricular Contraction (PVC)
Ventricular Tachycardia (V-tach)
Ventricular Fibrillation (V Fib)
Procainamide (Pronestyl) Nursing Considerations
Sympatholytics (Alpha & Beta Blockers)
Verapamil (Calan) Nursing Considerations
Adenosine (Adenocard) Nursing Considerations
Amiodarone (Pacerone) Nursing Considerations
Diltiazem (Cardizem) Nursing Considerations
Dysrhythmias Labs
Dysrhythmias for Certified Emergency Nursing (CEN)
AV Blocks Dysrhythmias for Progressive Care Certified Nurse (PCCN)
Cardiogenic Shock For PCCN for Progressive Care Certified Nurse (PCCN)
Nursing Care Plan (NCP) for Myocardial Infarction (MI)
Electrolytes Involved in Cardiac (Heart) Conduction
Nursing Care Plan (NCP) for Cardiomyopathy
3rd Degree AV Heart Block (Complete Heart Block)
2nd Degree AV Heart Block Type 2 (Mobitz II)
1st Degree AV Heart Block
Nursing Care and Pathophysiology of Coronary Artery Disease (CAD)
Advanced Cardiovascular Life Support (ACLS)
Acute Coronary Syndrome (ACS)
Nursing Care and Pathophysiology of Acute Respiratory Distress Syndrome (ARDS)
Obstructive Heart (Cardiac) Defects
Heart (Heart) Failure Exacerbation
Nursing Care and Pathophysiology of Myocardial Infarction (MI)
02.09 12 Lead EKG- Leads 1, 2, 3, aVL, and aVF for CCRN Review
02.14 Shock Stages for CCRN Review
02.15 Hypovolemic Shock for CCRN Review
02.16 Cardiogenic Shock for CCRN Review
02.17 Septic Shock for CCRN Review
Disseminated Intravascular Coagulation (DIC)
Nursing Care and Pathophysiology for Sepsis
Nursing Care and Pathophysiology for Distributive Shock
Sepsis Labs
Toxicity Sepsis- Signs and Symptoms Nursing Mnemonic (The 6 T’s)
Sepsis Concept Map
Ischemic (CVA) Stroke Labs
Nursing Care Plan (NCP) for Atrial Fibrillation (AFib)
Cardiopulmonary Arrest for Certified Emergency Nursing (CEN)
ACLS (Advanced cardiac life support) Drugs
Electrical A&P of the Heart
02.10 12 Lead EKG- Lead V1-V6 for CCRN Review
Nursing Care Plan (NCP) for Acute Respiratory Distress Syndrome
ARDS Case Study (60 min)
Acute Respiratory Distress Syndrome (ARDS) for Progressive Care Certified Nurse (PCCN)
Acute Respiratory Distress
HELLP Syndrome
Nursing Care Plan (NCP) for Respiratory Failure
Nursing Care and Pathophysiology for Arterial Disorders
Nursing Care Plan (NCP) for Arterial Disorders
Nursing Care and Pathophysiology for Cardiomyopathy
Nursing Care and Pathophysiology of Endocarditis and Pericarditis
Nursing Care and Pathophysiology for Heart Failure (CHF)
Restrictive Lung Diseases (Pulmonary Fibrosis, Neuromuscular Disorders)
Nursing Care and Pathophysiology for Thrombophlebitis (clot)
Venous Disorders (Chronic venous insufficiency, Deep venous thrombosis/DVT)
Rapid Sequence Intubation
Trach Suctioning
Trach Care
Pacemakers
Myocardial Infarction (MI) Case Study (45 min)
02.12 Myocardial Infarction- Inferior Wall for CCRN Review
Acute Coronary Syndromes (MI-ST and Non ST, Unstable Angina) for Progressive Care Certified Nurse (PCCN)
02.13 Myocardial Infarction – Anterior Septal Wall for CCRN Review
Fluid Volume Deficit
Sodium and Potassium Imbalance for Certified Emergency Nursing (CEN)
Cardiomyopathies (Dilated, Hypertrophic, Restrictive) for Progressive Care Certified Nurse (PCCN)
02.02 Cardiomyopathy for CCRN Review
Hydralazine
Valvular Heart Disease for Progressive Care Certified Nurse (PCCN)
Nursing Case Study for Rheumatic Heart Disease
06.04 Differentiating Ectopy and Aberrancy for CCRN Review
Coronary Artery Disease Concept Map
02.08 Cardiac Catheterization & Acute Coronary Syndrome for CCRN Review
Cardiac Surgery (Post-ICU Care) for Progressive Care Certified Nurse (PCCN)
Anti-Platelet Aggregate
Nursing Care Plan (NCP) for Cardiogenic Shock
Mixed (Cardiac) Heart Defects
Nursing Care and Pathophysiology of Angina
Nursing Care and Pathophysiology of Myocarditis
Nursing Care and Pathophysiology for Hypovolemic Shock
Nursing Care and Pathophysiology for Ischemic Stroke (CVA)
Nursing Care Plan (NCP) for Disseminated Intravascular Coagulation (DIC)
Nursing Care Plan (NCP) for Hypovolemic Shock
Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)
Nursing Care Plan (NCP) for Heart Valve Disorders
Nursing Care Plan (NCP) for Aortic Aneurysm
Nursing Care Plan (NCP) for Angina
Hemodynamics
Preload and Afterload
Nursing Care and Pathophysiology for Cardiogenic Shock
MI Surgical Intervention
Heart Failure for Certified Emergency Nursing (CEN)
02.05 Calculating PAWP on PEEP for CCRN Review
Heart Failure 2 – Live Tutoring Archive
Nitro Compounds
Cardiac/Vascular Catheterization (Diagnostic, Interventional) for Progressive Care Certified Nurse (PCCN)
Nursing Care and Pathophysiology for Valve Disorders
Cortisone (Cortone) Nursing Considerations
Dexamethasone (Decadron) Nursing Considerations
Famotidine (Pepcid) Nursing Considerations
Gastritis
Gastrointestinal (GI) Bleed Concept Map
Methylprednisolone (Solu-Medrol) Nursing Considerations
Nursing Care and Pathophysiology for Peptic Ulcer Disease (PUD)
Nursing Care Plan (NCP) for Anemia
Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed
Nursing Care Plan (NCP) for Peptic Ulcer Disease (PUD)
Parasympathomimetics (Cholinergics) Nursing Considerations
Peptic Ulcer Disease Case Study (60 min)
Tocolytics
Cholecystitis for Certified Emergency Nursing (CEN)
Nursing Care and Pathophysiology for Cholecystitis
Nursing Care Plan (NCP) for Cholecystitis
Cirrhosis Case Study (45 min)
Cirrhosis Complications Nursing Mnemonic (Please Bring Happy Energy)
Cirrhosis for Certified Emergency Nursing (CEN)
Esophageal Varices for Certified Emergency Nursing (CEN)
Hepatic Disorders (Cirrhosis, Hepatitis, Portal Hypertension) for Progressive Care Certified Nurse (PCCN)
Hepatitis for Certified Emergency Nursing (CEN)
Liver Cancer
Liver Function Tests
Nursing Care and Pathophysiology for Cirrhosis (Liver Disease, Hepatic encephalopathy, Portal Hypertension, Esophageal Varices)
Nursing Care and Pathophysiology for Hepatitis (Liver Disease)
Nursing Care Plan (NCP) for Encephalopathy
Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed
Nursing Care Plan (NCP) for Hepatitis
Nursing Care Plan for Cirrhosis (Liver)
Nursing Care Plan for Liver Cancer
Bowel Obstruction Concept Map
Epispadias and Hypospadias
Nursing Care Plan (NCP) for Bowel Obstruction
Nursing Care Plan for Hiatal Hernia
Cirrhosis Case Study (45 min)
Colorectal Cancer (colon rectal cancer)
Encephalopathy Case Study (45 min)
Fluid Shifts (Ascites) (Pleural Effusion)
Hepatic Disorders (Cirrhosis, Hepatitis, Portal Hypertension) for Progressive Care Certified Nurse (PCCN)
Liver Cancer
Nephrotic Syndrome
Nephrotic Syndrome Case Study (Peds) (45 min)
Nursing Care and Pathophysiology for Cirrhosis (Liver Disease, Hepatic encephalopathy, Portal Hypertension, Esophageal Varices)
Nursing Care and Pathophysiology of Nephrotic Syndrome
Nursing Care Plan (NCP) for Hepatitis
Nursing Care Plan (NCP) for Nephrotic Syndrome
Nursing Care Plan for Cirrhosis (Liver)
Nursing Care Plan for Liver Cancer
Nursing Case Study for Hepatitis
Stomach Cancer (Gastric Cancer)
Nursing Care and Pathophysiology for Cholecystitis
Nursing Care Plan (NCP) for Cholecystitis
Risk Factors for Cholelithiasis Nursing Mnemonic (5-F’s)
Acute Abdomen for Certified Emergency Nursing (CEN)
Appendicitis
Appendicitis for Certified Emergency Nursing (CEN)
Dialysis & Other Renal Points
Nursing Care and Pathophysiology for Diverticulosis – Diverticulitis
Nursing Care Plan (NCP) for Bowel Obstruction
Nursing Care Plan (NCP) for Constipation / Encopresis
Nursing Care Plan (NCP) for Diverticulosis / Diverticulitis
Peritoneal Dialysis (PD)
Peritonitis for Certified Emergency Nursing (CEN)
Cystic Fibrosis (CF)
Diabetes Mellitus (DM) Module Intro
Diabetes Mellitus & Those Dang Blood Sugars! – Live Tutoring Archive
Diabetes Mellitus Case Study (45 min)
Diabetes Mellitus for Progressive Care Certified Nurse (PCCN)
Diabetes Mellitus Type 1- Signs & Symptoms Nursing Mnemonic (The 3 P’s)
Diabetic Ketoacidosis (DKA) Case Study (45 min)
Hyperglycaemic Hyperosmolar Non-ketotic syndrome (HHNS)
Metabolic Acidosis (interpretation and nursing diagnosis)
Nursing Care and Pathophysiology of Diabetes Mellitus (DM)
Nursing Care and Pathophysiology of Diabetic Ketoacidosis (DKA)
Nursing Care Plan (NCP) for Chronic Kidney Disease
Nursing Care Plan (NCP) for Diabetes
Nursing Care Plan (NCP) for Diabetes Mellitus (DM)
Nursing Care Plan (NCP) for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
Nursing Case Study for Diabetic Foot Ulcer
Nursing Case Study for Type 1 Diabetes
Renal Failure- Acute Kidney Injury (AKI), Chronic Kidney Disease (CKD) for Progressive Care Certified Nurse (PCCN)
03.02 Diabetes Insipidus for CCRN Review
Diabetes Insipidus Case Study (60 min)
Diabetes Insipidus Nursing Mnemonic (DDD)
Enuresis
Nursing Care and Pathophysiology for Diabetes Insipidus (DI)
Nursing Care Plan (NCP) & Interventions for Increased Intracranial Pressure (ICP)
Nursing Care Plan (NCP) for Diabetes Insipidus
03.04 DKA vs HHNK for CCRN Review
05.01 Pancreatitis and Large Bowel Obstruction for CCRN Review
09.05 Chronic Renal Failure for CCRN Review
Adrenal Gland
Diabetes Management
Diabetes Mellitus Case Study (45 min)
Diabetes Mellitus for Progressive Care Certified Nurse (PCCN)
Diabetes Mellitus Type 1- Signs & Symptoms Nursing Mnemonic (The 3 P’s)
Diabetic Emergencies for Certified Emergency Nursing (CEN)
Diabetic Ketoacidosis (DKA) Case Study (45 min)
Diabetic Ketoacidosis for Progressive Care Certified Nurse (PCCN)
End-Stage Renal Disease (ESRD) for Progressive Care Certified Nurse (PCCN)
Gestational Diabetes (GDM)
Glipizide (Glucotrol) Nursing Considerations
Hyperglycaemic Hyperosmolar Non-ketotic syndrome (HHNS)
Hyperglycemia for Progressive Care Certified Nurse (PCCN)
Hyperglycemia Management Nursing Mnemonic (Dry and Hot – Insulin Shot)
Hypoglycemia for Progressive Care Certified Nurse (PCCN)
Hypoglycemia
Injectable Medications
Insulin
Insulin – Intermediate Acting (NPH) Nursing Considerations
Insulin – Long Acting (Lantus) Nursing Considerations
Insulin – Mixtures (70/30)
Insulin – Rapid Acting (Novolog, Humalog) Nursing Considerations
Insulin – Short Acting (Regular) Nursing Considerations
Insulin Drips
Insulin Mixing
Insulin Mnemonic (Ready, Set, Inject, Love)
IV Infusions (Solutions)
IV Pump Management
Hyperthyroidism Case Study (75 min)
Nursing Care and Pathophysiology for Hashimoto’s Thyroiditis
Nursing Care and Pathophysiology for Hyperthyroidism
Nursing Care and Pathophysiology for Hypothyroidism
Nursing Care Plan (NCP) for Hashimoto’s Thyroiditis
Nursing Care Plan (NCP) for Hyperthyroidism
Nursing Care Plan (NCP) for Hypothyroidism
Adrenal and Thyroid Disorder Emergencies for Certified Emergency Nursing (CEN)
09.02 Acute Tubular Necrosis for CCRN Review
Burn Injuries
Burn Injuries
Burn Injury Case Study (60 min)
Burns for Certified Emergency Nursing (CEN)
Compartment Syndrome for Certified Emergency Nursing (CEN)
Electrolyte Imbalances for Progressive Care Certified Nurse (PCCN)
Nursing Care Plan (NCP) for Burn Injury (First, Second, Third degree)
Nursing Care Plan (NCP) for Urinary Tract Infection (UTI)
Nursing Care Plan for Gastritis
Wound Care – Assessment
Wound Care – Selecting a Dressing