January 21 - Wound Care MEASURE

Question 1

M

Answer 1

Measure

• Length
• width
• depth

Question 2

E

Answer 2

Exudate

Amount
type
odour

Question 3

Appearance of wound base

Black wound
Yellow
Red/Pink

Answer 3

Black wound: devitalized tissue. May be grey, brown, black. Necrosis can be moist or dry.

Yellow wound: decaying collagen (slough) or fibrin.

Red/Pink wound: moist granulation tissue and indicates proliferating wound. May be shades of pink to red. Pink = new epithelialisation.

Question 4

S

Answer 4

Suffering

Pt pain level

Question 5

U

Undermining
Tunnel

Answer 5

Undermining- tissue destruction that occurs under intact skin around the wound perimeter

Tunnel- channel that extends from any part of wound through subcutaneous tissue or muscle

Question 6

R

Answer 6

Re-evaluate

All wounds should be reassessed regularly.

Question 7

E

Answer 7

Edge: Periwound

Intactness
Induration
Erythema
Temperature