how wounds heal/ wound assessment

Question 1

wound definition

Answer 1

any disruption to the layers of the skin and underlying tissues

Question 2

types of wounds?

Answer 2

pressure
venous
arterial
diabetic or neuropathic
incisional dehiscence 
trauma (includes skin tear)

Question 3

three layers of skin?

Answer 3

epidermis, dermis, subcutaneous

Question 4

superficial skin tears are confined to the layers of the?

Answer 4

epidermis and dermis

Question 5

superficial skin tears heal by?

Answer 5

reepithelialization

Question 6

wound healing past the dermis is a process known as?

Answer 6

scar formation

Question 7

three ways wounds heal?

Answer 7

primary intention
secondary intention
tertiary intention

Question 8

primary intention?

Answer 8

wounds that are surgically closed or approx by sutures/staples

Question 9

secondary intention?

Answer 9

wounds that have been left open and are left to hear by scar formation

Question 10

tertiary intention?

Answer 10

wound is intentionally opened for a number of time and closed surgically

Question 11

woulds that heal by secondary intention?

Answer 11

pressure, venous, arterial, diabetic or neuropathic, surgical dehision

Question 12

what does epithelialization mean

Answer 12

the wound healing process

Question 13

healing process (4)

Answer 13

hemostasis–> inflammation–> proliferation–> remodeling

Question 14

each phase of healing process must?

Answer 14

be completed in order for wound to close. if process is interrupted, wound will not close

Question 15

what is hemostasis?

Answer 15

immediate response, wound bleeds and begins clotting process

• fibrin clot seals off bleed
• • calcium and vitamins are important

Question 16

failure to clot in hemostasis may be because?

Answer 16

medications (anticoagulant) or low platelet count

Question 17

inflammatory response?

Answer 17

can last up to 4 days, occurs after bleeding is controlled

Question 18

inflammatory response is characterized by?

Answer 18

-erythema, induration, heat, pain
-focus: clean the wound bed
there is a break down of bacteria, foreign debris, damaged tissue

Question 19

factors that delay inflammatory response?

Answer 19

-steroids, chemo, advanced age, diabetes, necrotic tissue, foreign bodies, wound infection

Question 20

proliferation response?

Answer 20

starts around 4 days and can occur until 21 days

-filling in phase by granulation tissue. edges contract and wound starts to get surfaced by epithelial cells

Question 21

neoangiogenesis?

Answer 21

HUGE factor in wound healing. Wound needs good nutrients and protein/

Question 22

remodeling response?

Answer 22

after wound closure and up to 2 years

• after wound closes, collagen is added to make it stronger
• edges contract and the wound gets smaller

Question 23

factors that create the most risk to further damage?

Answer 23

infection and trauma

Question 24

to plan your care for a wound and figure out the goals, what must you know?

Answer 24

the history and etiology, “cause” of the wound

Question 25

surgical discence and trauma (skin tears) can occur where?

Answer 25

anywhere on the body

Question 26

where are pressure ulcers found

Answer 26

typically over bony prominences and occur anywhere there is pressure on skin that is not relieved

Question 27

where do arterial ulcers occur

Answer 27

prominent in the lower legs and feet due to decreased blood flow, restricted amount of oxygenated blood going to legs and feet causing harm

Question 28

where do venous ulcers occur

Answer 28

prominent in the lower legs (calf/ankle area) due to difficulty for blood to flow back up, impairs circulation returning to heart -valves of the veins in the calf muscle fail causing edema

Question 29

combo of arterial and venous ulcers?

Answer 29

often found due to circulatory issues in lower limbs; "mixed venous arterial"

Question 30

neuropathic/diabetic ulcers are found?

Answer 30

due to peripheral neuropathy, due to foot changes, trauma or pressure -often person can not feel their foot -

Question 31

furthest from center of body term

Answer 31

lateral

Question 32

closest to center of body term

Answer 32

medial

Question 33

when is wound assessment done?

Answer 33

weekly

Question 34

what is assessed in a wound assessment

Answer 34

wound pain, wound size, wound bed, wound exudate, wound edge, wound odour, periwound skin

Question 35

will pain affect wound healing?

Answer 35

yes due to hypoxia, identify type, cause, duration, location to help heal wound

Question 36

involving patient with wound care helps?

Answer 36

- allow them some control - reduces anxiety - adheres to care plan

Question 37

controlled pain increases risk of?

Answer 37

infection and delayed healing

Question 38

how is a wound measured?

Answer 38

in centimeters - length x width x depth (using simple disposable ruler) - always measure longest measurement and widest measurement

Question 39

how do you measure the depth of a wound

Answer 39

sterile swab or probe

Question 40

what is undermining?

Answer 40

destruction of tissue occuring underneath intact skin of the wound edge

Question 41

what is a sinus tract?

Answer 41

channel that extends in any part of wound base and tracks into deeper tissue

Question 42

to document the wound we use a imaginary..

Answer 42

clock, 12 oclock is head of the patient and 6 oclock is feet

Question 43

expected healing rate?

Answer 43

20-40% in 2-4 weeks

Question 44

eschar tissue?

Answer 44

dry, dead tissue (black or brown)

Question 45

slough tissue?

Answer 45

dry or wet, loose or firmly attached yellow or brown dead tissue

Question 46

granulation tissue?

Answer 46

desirable for healing, firm red and moist pebbled healthy tissue

Question 47

superficial pink, red tissue

Answer 47

desirable for healing, right at the surface, no depth

Question 48

tissues that dont help healing?

Answer 48

hypergranulation: raised above level of skin non-granulated tissue: moist red pale to bright, smooth look friable: unhealthy fragile skin that bleeds easily

Question 49

non-visible wound bed parts?

Answer 49

- tunnel - sinus tract - undermined area

Question 50

what is a blister

Answer 50

separation/elevation of the epidermis containing fluid

Question 51

wound exudate types?

Answer 51

- consider the amount and appearance | - serous, sanguinous sero-sanguinous, purulent, sanguinous purulent

Question 52

wound edges?

Answer 52

- diffuse - epithelialized - rolled - undermined - demarcated - callused

Question 53

attached wound edges?

Answer 53

-examples are diffuse and epithelialized, wound edges appear flushed with the wound bed

Question 54

unattached wound edges?

Answer 54

-examples are undermined and rolled, wound is not attached with wound bed

Question 55

unattached or attached wound edges?

Answer 55

demarcated and callused

Question 56

things that can cause rash on periwound skin?

Answer 56

frequent washing with soap/irritation contact dermatitis bacterial/fungal/inflammatory rashes= need more attention