Exam 2

Question 1

What are the 4 stages of wound healing?

Answer 1

1.) Homeostasis
2.) Inflammation
3.) Proliferation
4.) Remodeling

Question 2

Homeostasis:

Answer 2

• Blood vessels constrict to stop bleeding
• Blood clots form

Question 3

Inflammation:

Answer 3

• Preventing infection
• Neutrophils and Macrophages work to remove debris

Question 4

Proliferation:

Answer 4

• Granulation of skin
• Tissue repair
• Wound rebuilds connective tissue for protection

Question 5

Remodeling:

Answer 5

New epithelial tissue forms (New, Healthy Skin)

Question 6

What are the four stages of Pressure Ulcers and their Characteristics?

Answer 6

Stage 1: Skin intact, redness
Stage 2: Partial-thickness skin loss/ Epidermis and dermis exposed
Stage 3: Full-thickness skin loss/ Epidermis, Dermis and Adipose Tissue Exposed
Stage 4: Full-thickness skin loss / bone, tendons/ligaments and /or Muscle exposed
Unstageable: “Unseen” full-thickness skin and tissue loss but hidden by sloth or eschar
Deep tissue pressure injury: Intact skin, deep red, maroon or purple color

Question 7

What is slough?

Answer 7

The yellow/white material in the wound bed.

Question 8

What is eschar?

Answer 8

A collection of dry, dead tissue within a wound. Think Necrotic Tissue.

Question 9

What is secondary intention?

Answer 9

A wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally.

Question 10

What is primary intention?

Answer 10

The healing of a wound in which the edges are closely re-approximated. (closed together with Sutures, Staples, Stitches etc)

Question 11

What are the complications of wound healing?

Answer 11

1.) Infection
2.) Hemorrhaging
3.) Dehiscence
4.) Evisceration

Question 12

Dehiscence definition:

Answer 12

Wound edges separating. Ex.) Sutures, Stiches ect. Popping open.

Question 13

Hemorrhaging definition:

Answer 13

Loss of blood

Question 14

Evisceration definition:

Answer 14

Dehiscence occurs then organs leave the open wound.

Question 16

What nutrition is vital for wound healing?

Answer 16

Protein

Question 17

Wound VAC ( vacuum-assisted closure) device is an example of what healing intention?

Answer 17

Secondary intention

Question 18

What is the biggest difference between granulated tissue and Regular Tissue?

Answer 18

Unlike regular tissue granulated tissue is weak.

Question 19

Debridement:

Answer 19

Removal of dead or necrotic tissue to expose healthy tissue to provide an environment for better wound healing.

Question 20

What are the risk factors of Wound healing?

Answer 20

*Moisture: causes skin softening and breakdown

*Shear: sliding movement of skin while muscle and bone are stationary

*Friction: two surfaces being dragged against each other (skin and bed linens)

*Impaired mobility: inability to move causes prolonged pressure

*Pressure: prolonged compression

*Poor nutrition, less protein and calories means slower wound healing

Question 21

If a patient scores 16 or lower on the Braden scale how at risk are they?

Answer 21

They are at risk

Question 22

If a patient scores 9 or lower on the Braden scale how at risk are they?

Answer 22

They are at high risk.

Question 23

What is the highest possible score on the Braden scale?

Answer 23

23

Question 24

Braden scale: True or False

The higher the score the LESS at risk for skin breakdown

Answer 24

True