Wound Assessment

Front 1

What is the descriptive term for the yellow tissue?

Back 1

Slough

Front 2

What is the descriptive term for exudate that is clear, thin, and watery?

Back 2

Serous

Front 3

What is the descriptive term for exudate that is thin, watery, pale red to pink?

Back 3

Serosanguineous

Front 4

Wound measurements should be recorded in what order?

Back 4

Length X Width X Depth

Front 5

Wounds should be measured utilizing inches, centimeters, or fruit comparisons?

Back 5

Centimeters

Front 6

Length of a wound is measured from head to toe (12:00 - 6:00) or side to side (3:00-9:00)?

Back 6

Consider wound as face of clock. 12:00 points to patients head, 6:00 points toward patient’s feet.

Length = 12:00 – 6:00 using patients head & feet as guides

Width = 3:00 – 9:00 side to side

Front 7

What is the correct terminology for the black tissue?

Back 7

Eschar

Front 8

What is the correct terminology for the red bubbly tissue?

Back 8

Granulation

Front 9

What is the correct terminology for the light pink tissue seen at the edge of this wound?

Back 9

Epithelial

Front 10

What is the terminology for the white pale tissue?

Back 10

Maceration

Front 11

What is the red striated tissue seen in this wound?

Back 11

Muscle

Front 12

What is the name of the rolled tissue around the wound edges?

Back 12

Epibole

Front 13

What am I? A course or pathway that can extend in any direction from the wound, results in dead space with potential for abscess formation.

Back 13

Tunnel

Front 14

What am I? Tissue destruction underlying intact skin along the wound margins.

Back 14

Undermining

Front 15

What pressure ulcer stage?

Back 15

Stage I
Intact skin with non-blanchable redness of a localized area usually over a bony prominence

Front 16

What pressure ulcer stage?

Back 16

Suspected deep tissue injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Front 17

What pressure ulcer stage?

Back 17

Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Front 18

What pressure ulcer stage?

Back 18

Un-stageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Front 19

What pressure ulcer stage?

Back 19

Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Front 20

What pressure ulcer stage?

Back 20

Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.

Front 21

What is the terminology for the brown discoloration around this wound?

Back 21

Hemosiderin staining
Hyper-pigmentation stain of skin from leakage of red blood
cells into the tissue
(Results from venous hypertension)

Front 22

Where are venous ulcers typically located?

Back 22

Medial lower leg, ankle, malleolar area

Front 23

What type of wounds are categorized using the Payne-Martin Classification?

Back 23

Skin Tears

Front 24

What is the Braden Scale used for?

Back 24

Determining pressure ulcer risk

Front 25

Where are arterial ulcers typically located?

Back 25

Between toes or tips of toes, over phalangeal heads, around lateral malleolus or areas subjected to trauma/rubbing footwear.

Front 26

What is the anatomical terminology for toward the middle? Away from the middle?

Back 26

Medial - toward middle
Lateral - away from middle

Front 27

How often should wounds be assessed?

Back 27

Upon every dressing change, and documented at least weekly.

Front 28

Where are neuropathic (diabetic) ulcers typically located?

Back 28

Planter aspect of foot, under metatarsal heads, under heel and toes.