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NUR216 FINAL
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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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NUR216 FINAL

Concepts Covered:

  • Cardiac Disorders
  • Musculoskeletal Trauma
  • Integumentary Disorders
  • Neurologic and Cognitive Disorders
  • Oncology Disorders
  • EENT Disorders
  • Respiratory Disorders
  • Gastrointestinal Disorders
  • Hematologic Disorders
  • Communication
  • Test Taking Strategies
  • Pregnancy Risks
  • Fundamentals of Emergency Nursing
  • Concepts of Mental Health
  • Basics of NCLEX
  • Prioritization
  • Emotions and Motivation
  • Tissues and Glands
  • Skeletal System
  • Muscular System
  • Nervous System
  • Sensory System
  • Circulatory System
  • Hematologic System
  • Respiratory System
  • Digestive System
  • Urinary System
  • Endocrine System
  • Reproductive System
  • Labor Complications
  • Disorders of Pancreas
  • Eating Disorders
  • Neurological Emergencies
  • Noninfectious Respiratory Disorder
  • Vascular Disorders
  • Upper GI Disorders
  • Lower GI Disorders
  • Liver & Gallbladder Disorders
  • Urinary Disorders
  • Sexually Transmitted Infections
  • Female Reproductive Disorders
  • Renal Disorders
  • Integumentary Disorders
  • Integumentary Important Points
  • Immunological Disorders
  • Shock
  • Endocrine and Metabolic Disorders
  • Musculoskeletal Disorders
  • Musculoskeletal Disorders
  • Neurological Trauma
  • Central Nervous System Disorders – Brain
  • Central Nervous System Disorders – Spinal Cord
  • Peripheral Nervous System Disorders
  • Emergency Care of the Neurological Patient
  • Respiratory Emergencies
  • Infectious Respiratory Disorder
  • Oncologic Disorders
  • Studying
  • Cardiovascular Disorders
  • Basic
  • Adult
  • Pediatric
  • Neonatal
  • Emergency Care of the Trauma Patient
  • Emergency Care of the Cardiac Patient
  • Emergency Care of the Respiratory Patient

Study Plan Lessons

The 5-Minute Assessment (Physical assessment)
General Assessment (Physical assessment)
Integumentary (Skin) Assessment
Neuro Assessment
Head/Neck Assessment
EENT Assessment
Heart (Cardiac) and Great Vessels Assessment
Thorax and Lungs Assessment
Abdomen (Abdominal) Assessment
Lymphatic Assessment
Peripheral Vascular Assessment
Musculoskeletal Assessment
Genitourinary (GU) Assessment
Communicating with Patients
SATA
Absolute Words
Nursing Process
What do you want me to know?
Duplicate Facts
Repeating Words
Denying Feelings
NCLEX® Question Traps
Opposites
Same
Priority
Acute vs Chronic
Hierarchy of O2 Delivery
Nutrition Assessments
Abuse
Therapeutic Communication
Nurse-Patient Relationship
Thinking Like a Nurse
Critical Thinking
Prioritization
Triage
Maslow’s Hierarchy of Needs in Nursing
Overview of the Nursing Process
Skin Structure & Function
Skeletal Anatomy
Bone Structure
Development of Bones
Joints
Muscle Anatomy (anatomy and physiology)
Muscle Cytology
Skeletal Muscle
Muscle Contraction
Muscle Physiology
Nervous System Anatomy
Membrane Potentials
Nerve Transmission
Autonomic Nervous System (ANS)
Spinal Cord
Cranial Nerves
Sensory Basics
Intro to Circulatory System
The Heart
Cardiac Cycle
Electrical Activity in the Heart
Cardiac (Heart) Physiology
Blood Vessels
Blood Pressure (BP) Control
Blood Plasma
Blood Grouping
Vessels & Fluid
Respiratory Structure & Function
Breathing Movements
Breathing Control
Respiratory Functions of Blood
Digestive System Anatomy
Mouth & Oropharynx
Esophagus
Stomach Video
Small Intestine
Large Intestine
Liver & Gallbladder
Urinary System Anatomy (Anatomy and Physiology)
Renal (Kidney) Structure & Function
Renin Angiotensin Aldosterone System (RAAS)
Formation & Excretion of Urine
Renal (Kidney) Fluid & Electrolyte Balance
Renal (Kidney) Acid-Base Balance
Pituitary Gland
Thyroid Gland
Adrenal Gland
Pancreas
Male Reproductive Anatomy (Anatomy and Physiology)
Female Reproductive Anatomy (Anatomy and Physiology)
Epithelial (Skin) Tissues
Types of Epithelial (Skin) Tissue
Glands
Connective Tissues
Membranes
Fluid Compartments
Fluid Pressures
Fluid Shifts (Ascites) (Pleural Effusion)
Isotonic Solutions (IV solutions)
Hypotonic Solutions (IV solutions)
Hypertonic Solutions (IV solutions)
Potassium-K (Hyperkalemia, Hypokalemia)
Sodium-Na (Hypernatremia, Hyponatremia)
Calcium-Ca (Hypercalcemia, Hypocalcemia)
Chloride-Cl (Hyperchloremia, Hypochloremia)
Magnesium-Mg (Hypomagnesemia, Hypermagnesemia)
Phosphorus-Phos
Heart (Cardiac) Sound Locations and Auscultation
Nursing Care and Pathophysiology for Heart Failure (CHF)
Nursing Care and Pathophysiology of Myocardial Infarction (MI)
Nursing Care and Pathophysiology of Diabetes Mellitus (DM)
Nursing Care and Pathophysiology for Hemorrhagic Stroke (CVA)
Nursing Care and Pathophysiology of COPD (Chronic Obstructive Pulmonary Disease)
Nursing Care and Pathophysiology for Arterial Disorders
Nursing Care and Pathophysiology for Aortic Aneurysm
Venous Disorders (Chronic venous insufficiency, Deep venous thrombosis/DVT)
Nursing Care and Pathophysiology of Coronary Artery Disease (CAD)
GERD (Gastroesophageal Reflux Disease)
Nursing Care and Pathophysiology for Pancreatitis
Nursing Care and Pathophysiology for Diverticulosis – Diverticulitis
Nursing Care and Pathophysiology for Hemorrhoids
Nursing Care and Pathophysiology for Appendicitis
Nursing Care and Pathophysiology for Cholecystitis
Nursing Care and Pathophysiology for Hepatitis (Liver Disease)
Nursing Care and Pathophysiology for Cirrhosis (Liver Disease, Hepatic encephalopathy, Portal Hypertension, Esophageal Varices)
Nursing Care and Pathophysiology of Urinary Tract Infection (UTI)
Nursing Care and Pathophysiology of BPH (Benign Prostatic Hyperplasia)
Nursing Care and Pathophysiology for Syphilis (STI)
Nursing Care and Pathophysiology for Herpes Simplex (HSV, STI)
Nursing Care and Pathophysiology for Menopause
Nursing Care and Pathophysiology of Glomerulonephritis
Pressure Ulcers/Pressure injuries (Braden scale)
Nursing Care and Pathophysiology for Herpes Zoster – Shingles
Skin Cancer
Integumentary (Skin) Important Points
Nursing Care and Pathophysiology for Anaphylaxis
Nursing Care and Pathophysiology for Acquired Immune Deficiency Syndrome (AIDS)
Breast Cancer
Diabetes Management
Nursing Care and Pathophysiology for Sepsis
Fluid Volume Deficit
Fluid Volume Overload
Nursing Care and Pathophysiology for Rheumatoid Arthritis (RA)
Nursing Care and Pathophysiology of Osteoarthritis (OA)
Nursing Care and Pathophysiology of Osteoporosis
Nursing Care and Pathophysiology for Compartment Syndrome
Fractures
Casting & Splinting
Impulse Transmission
Cerebral Metabolism
Blood Brain Barrier (BBB)
Levels of Consciousness (LOC)
Routine Neuro Assessments
Adjunct Neuro Assessments
Brain Death v. Comatose
Intracranial Pressure ICP
Nursing Care and Pathophysiology for Multiple Sclerosis (MS)
Nursing Care and Pathophysiology for Myasthenia Gravis
Nursing Care and Pathophysiology for Parkinsons
Miscellaneous Nerve Disorders
Tension and Cluster Headaches
Migraines
Nursing Care and Pathophysiology for Ischemic Stroke (CVA)
Stroke Assessment (CVA)
Stroke Therapeutic Management (CVA)
Stroke Nursing Care (CVA)
Seizure Causes (Epilepsy, Generalized)
Seizure Assessment
Seizure Therapeutic Management
Nursing Care and Pathophysiology for Seizure
Neurological Fractures
Spinal Cord Injury
Nursing Care and Pathophysiology for Meningitis
Nursing Care and Pathophysiology for Asthma
Nursing Care and Pathophysiology of Acute Respiratory Distress Syndrome (ARDS)
Nursing Care and Pathophysiology for Pulmonary Edema
Nursing Care and Pathophysiology for Influenza (Flu)
Nursing Care and Pathophysiology for Tuberculosis (TB)
Nursing Care and Pathophysiology of Pneumonia
Isolation Precautions (MRSA, C. Difficile, Meningitis, Pertussis, Tuberculosis, Neutropenia)
Coronavirus (COVID-19) Nursing Care and General Information
Artificial Airways
Airway Suctioning
Nursing Care and Pathophysiology for Pneumothorax & Hemothorax
Nursing Care and Pathophysiology for Pulmonary Embolism
Lung Sounds
Alveoli & Atelectasis
Gas Exchange
Wound Care – Assessment
Aortic Aneurysm – Management Nursing Mnemonic (CRAM)
Aortic Aneurysm – Thoracic signs Nursing Mnemonic (PEE BADS)
Bacterial Endocarditis – Symptoms Nursing Mnemonic (Be Joan Of Arc)
Cardiac Valves Blood Flow Nursing Mnemonic (Toilet Paper my Ass)
Circulatory Checks (5 P’s) Nursing Mnemonic (The 5 P’s)
Coronary Arteries – Location Nursing Mnemonic (I have a RIGHT to CAMP if you LEFT off the AC)
Cor Pulmonale – Signs & Symptoms Nursing Mnemonic (Please Read His Text)
CHF Treatment Nursing Mnemonic (UNLOAD FAST)
Cyanotic Defects Nursing Mnemonic (The 4 T’s)
Heart Failure-Left-Sided Nursing Mnemonic (CHOP)
Heart Failure-Origin Nursing Mnemonic (Left – Lung|Right – Rest)
Heart Failure – Right Sided Nursing Mnemonic (HEAD)
Heart Sounds Nursing Mnemonic (APE To Man – All People Enjoy Time Magazine)
Hypertension- Complications Nursing Mnemonic (The 4 C’s)
Hypertension – Nursing care Nursing Mnemonic (DIURETIC)
Increase MAP Nursing Mnemonic (VAK)
Murmur locations Nursing Mnemonic (hARD ASS MRS. MSD)
Shock – Signs and symptoms Nursing Mnemonic (TV SPARC CUBE)
Vascular Disease – Deep Vein Thrombosis Nursing Mnemonic (HIS Leg Might Fall off)
Vascular disease – Raynaud’s symptoms Nursing Mnemonic (COLD HAND)
Digestion & Absorption
Nutrition-related Diseases
CPR-BLS (Basic Life Support)
Advanced Cardiovascular Life Support (ACLS)
Pediatric Advanced Life Support (PALS)
Neonatal Resuscitation Program (NRP)
Prioritizing Assessments
Triage in the ER
Critical Incident Management
Aggressive & Violent Patients
Legal & Ethical Issues in ER
EMTALA & Transfers
Trauma Survey
Blunt Thoracic Trauma
Penetrating Thoracic Trauma
Blunt Abdominal Trauma
Penetrating Abdominal Trauma
Crush Injuries
Head Trauma & Traumatic Brain Injury
Massive Transfusion Protocol
Acute Coronary Syndrome (ACS)
Aneurysm & Dissection
Cardiopulmonary Arrest
Dysrhythmia Emergencies
Heart (Heart) Failure Exacerbation
Hypertensive Emergency
Arterial Pressure Monitoring
Rapid Sequence Intubation
Pulmonary Embolism
Acute Respiratory Distress
Ventilator Settings
Acute Confusion
Intracranial Hemorrhage
Increased Intracranial Pressure
Stroke (CVA) Management in the ER
Seizure Management in the ER
Sodium and Potassium Imbalance for Certified Emergency Nursing (CEN)