3. an abnormally hard spot or place. A wound assessment is done as part of the overall client assessment (cardiorespiratory status, nutritional status, etc) b. As part of a thorough wound assessment, in addition to noting location and measuring size, the entire wound bed should be probed for the presence of tunneling and/or undermining.If you are unsure what tunneling and undermining are and how to recognize these phenomena, here's an explanation of these terms and how to assess wounds for … However, both required wound treatment and treatment of their underlying venous insufficiency to heal and remain healed. adj., adj indura´tive. This is important since the goal of wound care is to reduce wound severity. Peripheral tissue induration. The inflammatory stage, which is the first of the four stages of wound healing, might last from two to five days. It could be tender to the touch, so at this stage, the wound should be covered to keep it clean, moist and protected. It can be just a scratch or a cut that is as tiny as a paper cut.. A large scrape, abrasion, or cut might happen because of a fall, accident, or trauma. A person might notice that the wound is bleeding, and blood clots will typically begin to form at its surface. Documentation Guideline: Wound Assessment & Treatment Flow Sheet June 2011 Revised July 2014 1 GENERAL CONSIDERATIONS . You can do some things to avoid them, but most of us will get an infection on our skin at some point. Here is a lovely collection of wound care pictures. Viruses, bacteria, and fungi can all cause skin infections. a. Skin induration and Raynaud's phenomenon associated with typical visceral organ manifestations are sufficient to establish the diagnosis of SSc. During this time, the wound begins to heal itself from the inside and the body starts to repair any affected tissues. 9. Describe wound edges (approximated, rolled, calloused) Describe periwound skin (indurated, erythematous, macerated, healthy) Describe presence of excoriation, denudement, erosion, papules, pustules or other lesions; Induration - Abnormal hardening of the tissue caused by consolidation of edema, this may be a sign of underlying infection. The pictures below shows a small sore which would not heal along the inside of the ankle. Epithelialization. Both of these patients thought the small open sores would heal with home care. By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS. 13. A wound is a cut or opening in the skin. Immediately cleaning and dressing cuts, grazes, and other small wounds is the best way to prevent infections. •Wound – disruption of the integrity and function of tissues in the body (may be surgical) •Chronic wound – wound that does not follow the usual cycle of healing after 2-4 weeks •Ulcer – chronic wound with a defined pathophysiology –Ischemic arterial ulcers - Vasculitic ulcers –Diabetic ulcers - Rheumatoid ulcers Peripheral tissue edema. induration [in″du-ra´shun] 1. the quality of being hard. A wound infection can occur if bacteria enter and multiply inside the wound. 11. Skin color surrounding wound (assess tissues within 4 cm of wound edge) 10. Yellow: A wound this color, the handbook said, indicates the presence of exudate that is the result of microorganisms that have accumulated. Wound assessments are to be done and documented on the WATFS by an NP/RN/RPN/LPN/ESN/SN. Find out more from WebMD's slideshow. 12. 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