Term
| What to observe during wound examination (3) |
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Definition
1. location
2. size-LWD, acetate drawings, volume
3. appearance of wound bed-color, presence of eschar/necrotic tissue/coagulum, drainage (transudate/exudate), odor, margins, evidence of healing (granulation, epithelialization) |
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Term
| What to notice about the periwound skin (8) |
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Definition
1. edema
2. trophic changes (hairless, scaly skin, thick toenails, callus)
3. skin color
4. liposclerosis or induration
5. maceration of skin (excess moisture)
6. temperature
7. arterial assessment (pulses, rubor of dependency, cap refill test)
8. protective sensation (nylon filament) |
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Term
| Why is examining ROM of adjacent joints important? |
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Definition
| to determine if weight will be distributed appropriately during gait |
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Term
| What type of foot deformities may occur? (4) |
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Definition
1. hammer or claw toes
2. Charcot's foot = neuropathic fx
3. bony prominences
4. hallux limitus |
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Term
| What to note about footwear? (4) |
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Definition
1. proper fit-shoe length>foot length by 1/2"
2. excessive wear-esp. rough spots inside shoes
3. heel height-inc. heel height inc. forefoot pressure
4. composition of shoes-breathability of material dec. excessive skin moisture |
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Term
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Definition
1. functional exam
2. mental status-pt's understanding of wound care
3. emotional status-coping with chronic wounds
4. physical status-fxnal ability of pt to be compliant w/ wound care needs
5. family support
6. discharge env't |
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