Module 2: Surgical wound care, suture and staple removal

Question 1

What are the phases of wound healing?

Answer 1

1. Inflammatory phase
2. Proliferative phase
3. Maturation/remodeling

Question 2

What happens in the inflammatory phase?

Answer 2

Vasodilation occurs, which allows for the WBC and plasma to enter the wound and clean the wound bed, this can be seen as edema, erythema, and exudate.
Macrophages work to regulate the cleanup

Question 3

In the proliferative phase of wound healing, what are the four important processes?
How long does this phase last?

Answer 3

1. Epithelialization: new epidermis and granulation tissue are developed
2. New capillaries: angiogenesis Occurs to bring oxygen and nutrients to the wound
3. Collagen formation: this provides strength and integrity to the wound
4. Contraction: wound reduces in size
   (Day 3-14/21)

Question 4

What happens in the maturation/remodeling phase?

Answer 4

Collagen continues to strengthen the wound and the wound forms into a scar.
Early: 2-3 weeks to 6 weeks, Collagen is reorganized into a more orderly structure, raised scar formation
Later: 6 weeks, to 1-2 years, Scar tissue has 80% of original tissue strength, flat, thin scar

Question 5

Describe wound healing by primary intention

Answer 5

• Wound is clean with straight edges, as in a surgical incision
• Edges can be approximated with sutures, Staples, or tape
• Healing is rapid and primarily by collagen synthesis
• Scars usually thin and flat

Question 6

Describe wound healing by secondary intention

Answer 6

• Wound is large and irregular with considerable tissue loss, as in pressure ulcer or deep abrasion
• Healing involves inflammation, filling with granulation tissue, and epithelialization
• Scar is usually large and pronounced

Question 7

Describe wound healing by tertiary intention

Answer 7

• Wound is left open because of possible contamination or debris
• Healing involves some granulation tissue and increased inflammation and risk of infection
• Edges are approximated as well as possible with sutures once wound is clean
• Scar varies with wound

Question 8

What do you assess on the wound?

Answer 8

Redness
Edema
Ecchymosis
Drainage
Approximation

Question 9

What is the drainage assessment?

Answer 9

Type
Amount
Colour and consistency
Odour

Question 10

How do acute wounds heal?

Answer 10

Orderly and timed repair process, resulting restoration of anatomical and functional integrity (trauma, surgical incision]

Question 11

How does a chronic wound heal?

Answer 11

Fails to proceed through and orderly and timely repair process
(Causes - vascular compromise, chronic inflammation, or repetitive insults to the tissue)

Question 12

What is an abrasion?

Answer 12

Superficial with little bleeding and it’s considered a partial thickness wound. Appears weepy because of plasma leakage from damaged capillaries

Question 13

Describe a laceration Wound?

Answer 13

Jagged, unintentional (i.e. nonsurgical) wound, sometimes bleeds more profusely, depending on the wounds depth and location.

Question 14

Within 7 to 10 days, or normal healing wound resurfaces with

Answer 14

Epithelial cells and edges close

Question 15

What are some intrinsic factors affecting wound healing

Answer 15

Health status, diabetes, circulation, anemia, immune status, age, etc.

Question 16

What are some extrinsic factors that affect wound healing?

Answer 16

Mechanical stress, debris, micro organisms, temperature, infection, medication

Question 17

What is a hemorrhage and when is the risk for it the highest?

Answer 17

Bleeding from a wound site, normal during and immediately after initial trauma but not after hemostasis has occurred.
Risk is high during first 24 to 48 hours after surgery or injury

Question 18

What is dehiscence?

Answer 18

Partial or total separation of layers

- Patient at risk for poor wound healing are at risk for poor nutrition, infection, obesity

Question 19

Evisceration is? As a nurse what do you do to reduce infection?

Answer 19

Protrusion of visceral organs through a wound opening.
Surgical repair: As a nurse you must play sterile towels so soaked and sterile saline over the extruding tissue to reduce chance of infection

Question 20

What is this fistula?

Answer 20

Abnormal passage between two organs or between an organ and the outside of the body

Question 21

Clear, watery plasma is what type of drainage?

Answer 21

Serous

Question 22

Pale, red, watery: mixture of clear and red fluid is the Appearance of what type of drainage?

Answer 22

Serosanguineous

Question 23

Thick, yellow, green, tan, or brown drainage is what type

Answer 23

Purulent

Question 24

Bright red: indicates active bleeding is known as what type of drainage?

Answer 24

Sanguineous

Question 25

Describe suspect a deep tissue injury

Answer 25

Intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister

Question 26

Stage one pressure injury

Answer 26

Intact skin with a localized area of non-blanchable erythema. Color changes do not include purple or maroon discoloration

Question 27

Stage 2 pressure injury

Answer 27

Partial thickness loss of skin with exposed dermis. Wound bed is viable, pink or red, and moist and me also present as an intact or ruptured serum filled blister. NO granulation tissue, slough, eschar visible.

Question 28

Stage III pressure injury

Answer 28

Full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough, eschar or both may be visible

Question 29

Stage four pressure injury

Answer 29

Full thickness skin and tissue loss with exposed or directly palpable faster, muscle, tendon, ligament, cartilage, or bone in ulcer.

Question 30

Describe granulation tissue

Answer 30

Red and white tissue, composed of new blood vessels, indicating progression of wound healing

Question 31

Describe slough tissue

Answer 31

Soft yellow, or white stringy tissue which needs to be removed before wound healing occurs (dead tissue)

Question 32

Describe eschar tissue

Answer 32

Black or brown necrotic tissue, which needs to be removed before wound will heal

Question 33

Differentiate between nonabsorbent and absorbent sutures

Answer 33

Nonabsorbent: must be removed, and are usually removed within 7 to 14 days
Absorbent: Can be dissolved and do not have to be removed

Question 34

What is the purpose of steri strips?

Answer 34

Support the wound tension across the wound and eliminate scarring.
This allows the wound to heal by primary intention
They should extend 1.5 to 2 cm on each side of the incision