Skin & Wound Assessment

Skin & Wound assessment

Skin Assessment

Circulation

Palpate

Inspect

Lab data

Wound Assessment

Sutures/Staples

Drainage

Appearance

Complications/Pain

FILL IN THE BLANK COCA GAME

Watery or clear drainage is refered to as _____________ drainage.

Serous

serous

Sanguineous

Serosanguineous

Bloody drainage is known as _____________ .

sanguineous

Serous

Sanguineous

Serosanguineous

FILL IN THE BLANK COCA GAME

Serosanguineous

Pale or red/pink drainage is known as ________________ .

Serous

serosanguineous

Purluent

Exudate

Drainage that is thick, yellow, green, or tan is known as _____________ .

Purulent

purulent

Serosanguineous

Sanguineous

Drainage that is full of fluid and cells is known as ____________.

Serous

exudate

Exudate

Wound Drains

• Into or close to surgical wound if large amount of drainage is expected

• Connected to drainage bag or suction apparatus

01

Penrose

02

T-tube

03

Jackson-Pratt (JP)

04

Hemovac

Norton Scale

BradenScale

Inspect

1. Good lighting
2. Recent changes
3. Breaks in integrity
4. Pressure areas

Penrose drains promote the movement of drainage from high pressure (the wound) to low pressure). Attached with a safety pin.

Palpation

1. Temperature
2. Turgor
3. Edema (pitting?) How do you rate edema?

Used to drain bile duct post gallbladder surgery. This type of drain is not sutered but taped down. It's considered a closed system.

Sutures/Staples

1. Assess the presence and what they look like

• LPNs can remove staples and sutures! We'll talk more about this in later lecutres

Closed system. Decreases dead space by collecting drainage. Work by pressure - when you go to empty the drain you will "squeeze" it together and it will fill back up with fluid from the wound/incision. These are sutered to their skin. Watch the video above to see how they're inserted!

Lab data

1. Leukocytes (decreased can delay wound healing, increased = infection)
2. Coagulation studies
3. Protein
4. Wound cultures

COCA

1. COLOR 2. ODOR 3. CONSISTENCY 4. AMOUNT

COCA quiz

1. Type of wound2. Location 3. Size (LxWxD) 4. Wound bed (if open) 5. Wound edges 6. Color of wound and surrounding area 7. Tunneling/undermining

Works to decrease the dead space by collecting the drainage. Sutered to the patient's skin.

Complications/Pain

1. Note any complications
2. Assess PQRST
1. What makes pain worse?
2. What makes pain better?

• If you're about to change a dressing what do you need to do in regards to pain?

Circulation

1. Pulses
2. Color
3. Temperature
4. Sensation

• What can poor circulation lead to?