Skin & Wound Assessment

Skin & Wound assessment

Lab data

Circulation

Palpate

Inspect

Skin Assessment

Complications/Pain

Sutures/Staples

Drainage

Appearance

Wound Assessment

sanguineous

Bloody drainage is known as _____________ .

serous

Watery or clear drainage is refered to as _____________ drainage.

FILL IN THE BLANK COCA GAME

Serosanguineous

Serosanguineous

Sanguineous

Sanguineous

Serous

Serous

exudate

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

purulent

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

FILL IN THE BLANK COCA GAME

Purluent

Exudate

Serosanguineous

Purulent

Serous

Serous

Exudate

Serosanguineous

Sanguineous

serosanguineous

Pale or red/pink drainage is known as ________________ .

• Connected to drainage bag or suction apparatus

Wound Drains

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

Hemovac

Jackson-Pratt (JP)

T-tube

04

03

02

01

Penrose

BradenScale

Norton Scale

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

Inspect

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

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

Palpation

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

1. Assess the presence and what they look like

Sutures/Staples

• 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!

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

Lab data

COCA quiz

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

COCA

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.

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

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

Complications/Pain

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

Circulation

• What can poor circulation lead to?