*9.PTA 200-Wound Management Part 2

Question 1

Designed for use with wounds whose primary cause is something other than pressure. This is typically the classification system for burns, skin tears, lacerations, surgical wounds and vascular ulcers.

Answer 1

Classification by thickness;

Superficial, Partial, Full

Question 2

into only the epidermis

Answer 2

Superficial

Question 3

Wounds extend through the first layer of skin (the epidermis) and into, but not through, the second layer of skin (dermis). Wounds heal by re-epithelialization.

Answer 3

Partial thickness

Question 4

wounds extend through both the epidermis and dermis and may involve subcutaneous tissue, muscle, and possibly bone. (grafting/flaps are necessary)

Answer 4

Full thickness

Question 5

Designed for use with traumatic, surgical, and other wounds that heal by secondary intention

Answer 5

Classification by Color;

Question 6

refers to healing in wounds that start out with large surface areas, with distracted edges, or wounds in which a large amount of tissue has been lost.

Answer 6

Secondary Intention

Question 7

healing occurs in wounds where the edges which have been closely approximated by sutures or staples.

Answer 7

Primary Intention

Question 8

refers to a wound left open for several days (to insure no infection is present) before wound is closed with suture/steri-strips, etc.

Answer 8

Delayed Primary Intention

Question 9

Indicates clean, healthy granulation tissue. When a wound begins to heal, a layer of pale pink granulation tissue covers the wound bed, which later becomes beefy red.

Answer 9

Red Wound

Question 10

Indicates the presence of exudate or slough produced by microorganisms and the need for cleaning. Exudate can be whitish yellow, creamy yellow, yellowish green, or beige.

Answer 10

Yellow Wound

Question 11

a fluid with a high content of protein and cellular debris which has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation.

Answer 11

Exudate- in relation with yellow wound

Question 12

necrotic fatty tissue in the process of being separated from viable portions of the body.

Answer 12

Slough- in relation with yellow wound

Question 13

Indicates the presence of eschar. Necrotic tissue slows healing and provides a site for microorganisms to proliferate.

Answer 13

Black wound

Question 14

a slough produced by gangrene.

Answer 14

eschar- in relation with black wound

Question 15

Document and describe length and width only.

Answer 15

Stage I Measurements for Pressure Ulcers

Question 16

Document and describe length, width, and depth. Ulcer depth may be documented as > 1mm in depth.

Answer 16

Stage II Measurements for Pressure Ulcers

Question 17

Document and describe length, width and depth; tunneling (if present)

Answer 17

Stage III Measurements for Pressure Ulcers

Question 18

Document and describe length, width and depth; tunneling (if present) and underlying support structures (fascia, muscle, and bone.)

Answer 18

Stage IV Measurements for Pressure Ulcers

Question 19

a term used for moisture saturated skin – usually in the periwound area

Answer 19

Maceration

Question 20

Wound description color and consistency

Answer 20

Serous: Clear, watery plasma.
Sanguinous: Bloody
Sero-Sanguinous: Plasma and red blood cells.
Purulent: Thick, white blood cells may be yellow, green or brown, if infected.

Question 21

Wound Tracing
Clear food wrap next to wound
Transparency over food wrap
Transparency is copied
Commercial 2-part transparencies are also available.	 

Photography: Patients would have to sign a release to be photographed; close up photography is then taken.

Answer 21

Other Methods of Wound Documentation(Not a substitute for other written documentation!)This is “above and beyond” documentation

Question 22

the removal of necrotic, dead or devitalized tissue.

Goal is to remove the dead tissue from the wound.

Answer 22

Debridement

Question 23

Selective vs. Non Selective

Answer 23

Selective – removes specific devitatlized tissue

Nonselective – removes non-specific areas of devitalized tissue

Question 24

↓bacterial concentration within the wound bed and the risk of infection
↑the effectiveness of topical antimicrobials
Improve the bacterididal activity of leukocytes
↓the inflammatory phase of wound healing
↓energy required by the body for wound healing
Eliminate the physical barrier to wound healing
↓ wound odor

Answer 24

Purposes for Debridement(page 71, Wound Management Principles and Practice)

Question 25

edges of the top layer of the epidermis roll down to cover lower edge of epidermis, causing the inability of epithelial cells to migrate from wound edges. Wound healing cannot take place in this circumstance.

Answer 25

Epiboly