Module 2 - Surgical Wound Care: suture and staple removal

Question 1

Acute

Answer 1

proceeds through an orderly and timely repair process; results in restoration of anatomical and functional integrity
Causes: trauma, surgical incision

Question 2

Chronic

Answer 2

fails to proceed through an orderly and timely repair process to produce anatomical and functional integrity
Causes: vascular compromise chronic inflammation, repetitive insults to the tissue

Question 3

pressure ulcer

Answer 3

impaired skin integrity related to unrelieved, prolonged pressure; localized injury to skin and underlying tissue (usually over a bony prominence) as a result of pressure, or in combination with shear/friction

Question 4

Braden scale

Answer 4

Risk assessment tool highly reliable when used to identify patients at greatest risk of pressure ulcers, the lower the score the greater the risk

Question 5

Suspected deep tissue injury (staging pressure ulcers)

Answer 5

purple of maroon localized area of discolored intact skin or blood filled blister due to damaged underlying skin

Question 6

Stage I

Answer 6

intact skin with nonblanchable redness

Question 7

Stage II

Answer 7

partial-thickness skin loss involving epidermis, dermis, or both

Question 8

Stage III

Answer 8

Full thickness tissue loss. SC fat may be visible but no other underlying structures exposed

Question 9

Stage IV

Answer 9

Full thickness tissue loss with exposed bone, tendon, or muscle

Question 10

unstageable

Answer 10

full thickness tissue loss in which the base of the ulcer is covered by slough, eschar or both

Question 11

granulation

Answer 11

red, moist tissue composed of new blood vessels which indicated progression of wound healing

Question 12

slough

Answer 12

soft yellow or white stringy tissue which needs to be removed before wound will heal (dead tissue)

Question 13

eschar

Answer 13

black or brown necrotic tissue which needs to be removed before wound will heal (dead tissue)

Question 14

Venous ulcers

Answer 14

due to poor circulation; the most common type of lower extremity wound - superficial and irregular in shape, large amount of exudate

Question 15

Arterial ulcer

Answer 15

due to poor circulation - “punched out “ appearance, deeper and smaller than venous ulcer

Question 16

primary intention

Answer 16

• skin edges are approximated with sutures, staples or tape
• low infection risk
• quick healing with minimal scar
• surgery wound heals by this

Question 17

secondary intention

Answer 17

• wound is large and irregular with considerable tissue loss
• edges are not approximated
• longer healing time with pronounced scarring
• higher infection risk

Question 18

tertiary intention

Answer 18

• wounds left open due to possible contamination - require observation
• edges approximated once would is clean

Question 19

phases of wound healing

Answer 19

Inflammatory phase - incision to post op day 2, hemostasis, phagocytosis, with mild redness and swelling

Proliferative phase - day 3 - 14 -21, collagen strengthens wound, produces scar tissue, granulation tissue is highly vascular. Wound bed whitish then translucent red/friable. Raised healing ridge on sutured wound

Maturation Phase (early) - 2-3 weeks to 6 weeks, collagen reorganized into more orderly structure. Raised scar formation

Maturation Phase (later) - 6 weeks to 1-2 years. Scar tissues has < 80% of original tissue strength. Flat, thin scar.

Question 20

intrinsic factors affecting wound healing

Answer 20

health status, diabetes, circulation, anemia, immune status, age, nutritional status/fluid balance

Question 21

Extrinisic factors affecting wound healing

Answer 21

mechanical stress, debris, microorganisms, temperature, infection, chemical stress, medication, radiation

Question 22

hemorrhage

Answer 22

(bleeding from a wound site) normal during and immediately after initial trauma but not after hemostasis has occurred

internal - look for distension or swelling a change in the type and amount of drainage, or signs of hypovolemic shock
external - look for amount of saturation to dressing

risk of hemorrhage is greatest during the first 24-48 hours after surgery or injury

Question 23

dehiscene

Answer 23

partial or total separation of wound layers

Question 24

evisceration

Answer 24

protrusion of visceral organs through a wound opening

Question 25

fistula

Answer 25

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

Question 26

REEDA

Answer 26

redness
edema
ecchymosis
drainage
approximation

Question 27

TACO

Answer 27

type
amount
colour and consistency
odor

Question 28

serous drainage

Answer 28

clear, watery plasma

Question 29

purulent

Answer 29

thick, yellow, green, tan or brown

Question 30

serosanguineous

Answer 30

pale, red, watery; mixture of clear and red fluid

Question 31

sanguineous

Answer 31

bright red: indicates active bleeding

Question 32

Types of sutures

Answer 32

Intermittent : surgeon ties individual suture made in skin
Continuous: series of sutures with only two knots (one at the beginning and one at the end)
Retention: places more deeply than skin sutures, nurses may or may not remove them depending on policy