Ch.28 Wound Care

Question 1

A ____________ is damaged skin or soft tissue that results from trauma.

Answer 1

Wound

Question 2

____________ is the physiologic defense immediately after tissue injury that lasts for approximately 2 to 5 days.

Answer 2

Inflammation

Question 3

____________ is a process by which the white blood cells consume pathogens, coagulated blood, and cellular debris.

Answer 3

Phagocytosis

Question 4

____________ is the period during which new cells fill and seal a wound, and it occurs from 2 days to 3 weeks after the inflammatory phase.

Answer 4

Proliferation

Question 5

____________ (a period during which the wound undergoes changes and maturation) follows the proliferative phase and may last 6 months to 2 years.

Answer 5

Remodeling

Question 6

____________ debridement is appropriate for uninfected wounds or for clients who cannot tolerate sharp debridement.

Answer 6

Enzymatic

Question 7

One of the chief advantages of ____________ dressings is that they allow a nurse to assess a wound without removing the dressing.

Answer 7

Transparent

Question 8

____________ are tubes that provide a means for removing blood and drainage from a wound.

Answer 8

Drains

Question 9

____________ are knotted ties, generally constructed from silk or synthetic materials such as nylon, which hold an incision together.

Answer 9

Sutures

Question 10

A ____________ is a type of bandage generally applied to a particular body part such as the abdomen or breast.

Answer 10

Binder

Question 11

Identify the type of dressing.

Answer 11

The image is that of a transparent dressing.

Question 12

What is the chief advantage of using a tranparent dressing?

Answer 12

The chief advantage of a transparent dressing is that it allows the nurse to assess a wound without removing the dressing. In addition, it is less bulky than gauze dressings and does not require tape because it consists of a single sheet of adhesive material. It commonly is used to cover peripheral and central intravenous insertion sites.

Question 13

Surface of the skin or mucous membrane is no longer intact

Answer 13

Open Wound

Question 14

Occurs more often from blunt trauma or pressure

Answer 14

Closed Wound

Question 15

A combination of new blood vessels, fibroblasts, and epithelial cells

Answer 15

Granulation tissue

Question 16

A reparative process during which the wound edges are directly next to each other

Answer 16

First-intention healing

Question 17

Wound caused by prolonged capillary compression

Answer 17

Pressure ulcer

Question 18

Presented here, in random order, are descriptions of the stages of a pressure ulcer. Place them in the correct sequence in the boxes provided.

1. Ulcer is red and accompanied by blistering or skin tear.
2. Tissue is deeply ulcerated, exposing muscle and bone.
3. Characterized by intact but reddened skin.
4. Ulcer has a shallow skin crater that extends to the subcutaneous tissue.

Answer 18

3. Characterized by intact but reddened skin.
4. Ulcer is red and accompanied by blistering or skin tear.
5. Ulcer has a shallow skin crater that extends to the subcutaneous tissue.
6. Tissue is deeply ulcerated, exposing muscle and bone.

Question 19

What is the purpose of inflammation during the process of wound repair?

Answer 19

Inflammation is the physiologic defense, immediately after tissue injury, which lasts for approximately 2 to 5 days. The purpose of inflammation is to:

Limit the local damage
Remove injured cells and debris
Prepare the wound for healing

Question 20

How is the integrity of skin and damaged tissue restored?

Answer 20

Generally, the integrity of skin and damaged tissue is restored by:

Resolution, a process by which damaged cells recover and reestablish their normal function.

Regeneration or cell duplication

Scar formation, which is the replacement of damaged cells with fibrous scar tissue. Fibrous scar tissue acts as a nonfunctioning patch. The extent of scar tissue that forms depends on the magnitude of tissue damage and the manner of wound healing.

Question 21

What are the factors that affect wound healing?

Answer 21

Several factors that affect wound healing include

Type of wound injury 
Expanse or depth of wound 
Quality of circulation 
Amount of wound debris 
Presence of infection 
Status of the client’s health

Question 22

What are the factors that affect blood flow to the injured tissue?

Answer 22

The key to wound healing is adequate blood flow to the injured tissue. Factors that may interfere include compromised circulation; infection; and purulent, bloody, or serous fluid accumulation that prevents skin and tissue approximation. In addition, excessive tension and pulling on wound edges contribute to wound disruption and delay in healing. One or several of these factors may be secondary to poor nutrition or impaired inflammatory or immune responses secondary to drugs like corticosteroids and obesity.

Question 23

What are the possible causes of surgical wound complication?

Answer 23

Two potential surgical wound complications include dehiscence (the separation of wound edges) and evisceration (wound separation with protrusion of organs). These complications are most likely to occur within 7 to 10 days after surgery. They may be caused by an insufficient dietary intake of protein and sources of vitamin C; premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; weak tissue or muscular support secondary to obesity; distension of the abdomen from accumulated intestinal gas; or compromised tissue integrity from previous surgical procedures in the same area.

Question 24

What purpose does the dressing of a wound serve?

Answer 24

A dressing or a cover over a wound is used to

Keep the wound clean 
Absorb drainage
Control bleeding 
Protect the wound from further injury 
Hold medication in place 
Maintain a moist environment

Question 25

Heat and cold have various therapeutic uses and each can be used in several ways. Examples include an ice bag, collar, chemical pack, compress, and aquathermia pad. Answer the following questions involving a nurse’s role in the application of a compress.

A nurse is caring for a 2-year-old client who is being treated for viral fever at a health care facility. The nurse uses a cold compress for the child.

What is the purpose of a cold compress?

Answer 25

The nurse applies the cold compress to reduce the temperature of the client.

Question 26

*A nurse is caring for a 2-year-old client who is being treated for viral fever at a health care facility. The nurse uses a cold compress for the child.

How should the nurse apply the compress to the client?

Answer 26

Before applying the compress, the nurse soaks it in tap water or medicated solution at the appropriate temperature and then wrings out excess moisture. To maintain the moisture and temperature, a piece of plastic or plastic wrap is used to cover the compress, and the area is secured in a towel. As the compress material cools or warms outside the range of the intended temperature, the nurse removes it and reapplies it if necessary.