module 5 - Skin integrity and Wound care

Question 1

Acute wound

Answer 1

a wound that heals within an expected time frame ( a surgical wound for instance)

Question 2

Chronic wound

Answer 2

a wound that doesn’t heal in an orderly and timely process

Question 3

braden scale

Answer 3

common took used to identify patients at greatest rick of developing pressure ulcers. Total score ranges from 6-23 and the lower the score indicates a higher risk of pressure ulcer development

Question 4

suspected deep tissue injury

Answer 4

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

Question 5

Stage I (pressure ulcer classification)

Answer 5

intact skin with nonblanchable redness

Question 6

Stage II (pressure ulcer classification)

Answer 6

partial-thickness skin loss involving epidermis, dermis or both

Question 7

Stage III (pressure ulcer classification)

Answer 7

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

Question 8

Stage IV (pressure ulcer classification)

Answer 8

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

Question 9

unstageable (pressure ulcer classification)

Answer 9

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

Question 10

define slough

Answer 10

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

Question 11

define eschar

Answer 11

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

Question 12

venous ulcer

Answer 12

caused by poor blood return

Question 13

arterial ulcer

Answer 13

caused by inadequate blood flow

Question 14

diabetic ulcer

Answer 14

occur because of neuropathic changes related to diabetes

Question 15

primary intention

Answer 15

• wound is clean with straight edges as in a surgical incision
• edges can be approximated with sutures, staples or tape
• infection risk is low
• healing occurs quickly minimal scar formation

Question 16

secondary intention

Answer 16

• wound is large and irregular with considerable tissue loss (pressure ulcer)
• longer healing time
• edges not approximated and healing occurs by granulation tissue
• scar is usually large and pronounced

Question 17

tertiary intention

Answer 17

• wound left open due to possible contamination or debris

- edges approximated as well as possible with sutures one wound is clean

Question 18

what are the steps to cleaning a wound?

Answer 18

1) clean in the direction from the least contaminated area to surrounding skin
2) use gentle friction when applying solutions locally to skin
3) when irrigating, allow the solution to flow from the least to most contaminated area.

Question 19

Assessing a wound

Answer 19

R - redness
E - edema
E - ecchymosis
D - drainage
A -approximation

Question 20

Assessing drainage

Answer 20

T - type of drainage
A - amount
C - colour and consistency
O - Odour

Question 21

types of drainage

Answer 21

serous - clear, watery plasma
purulent - thick, yellow, green tan or brown
serosanguineous -pale, red, watery: mixture of clear and red fluid
Sanguineous - bright red: indicates active bleeding

Question 22

granulation

Answer 22

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

Question 23

dehiscence

Answer 23

partial or total separation of wound layers

Question 24

evisceration

Answer 24

protrusion of visceral organs through wound opening

Question 25

fistulas

Answer 25

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

Question 26

DARP

Answer 26

Data, Action, Response, Plan

Question 27

define erythema (hyperemia)

Answer 27

excess blood in vessels, the skin turns red because of the vasodilation

Question 28

Vitamin c is necessary for what

Answer 28

synthesis of collagen

Question 29

6 categories of the Braden Scale are

Answer 29

sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

Question 30

in a clean wound what controls bleeding

Answer 30

inflammatory stage

Question 31

describe how you would remove tape from a dressing

Answer 31

pull parallel to skin toward dressing