Module 5: Skin Integrity & Wound Care

Question 1

What are the steps in assessing a wound?

Answer 1

Redness
Edema (swelling)
Ecchymosis (bruising)
Drainage
Approximation (closed = approximation)

Question 2

What to assess in wound drainage

Answer 2

T - Type of drainage
A - Amount
C - Colour and consistency
O - Odour

Question 3

What is an acute wound?

Answer 3

I wound that heals in an expected timeframe

Surgical wound

Question 4

Classification of pressure ulcers:

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

Answer 4

Suspected deep tissue injury

Question 5

Classification of pressure ulcers:

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

Answer 5

Stage 2

Question 6

Classification of pressure ulcers:

Intact skin with nonblanchable redness

Answer 6

Stage 1

Question 7

Classification of pressure ulcers:

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

Answer 7

Stage 3

Question 8

Classification of pressure ulcers:

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

Answer 8

Stage 4

Question 9

Classification of pressure ulcers:

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

Answer 9

Unstageable

Question 10

How are venous ulcers caused?

Answer 10

Poor blood return

Question 11

How are arterial ulcers caused?

Answer 11

Inadequate blood flow

Question 12

How are diabetic ulcers caused?

Answer 12

Neuropathic changes related to diabetes

Question 13

wound healing by primary intention

Answer 13

• 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 with minimal scar formation

Question 14

Wound healing by secondary intention

Answer 14

• Wound is large and irregular with considerable tissue loss (ex. pressure ulcer)
• Longer healing time
• Edges not approximated and healing occurs by granulation tissue
• Scar is usually large and pronounced

Question 15

Wound healing by tertiary intention

Answer 15

• Wound left open due to possible contamination or debris

- Edges approximated as well as possible with sutures once wound is clean

Question 16

What are the phases of wound healing?

Answer 16

Inflammatory phase, proliferative phase, maturation phase

Question 17

What happens in the inflammatory phase of the wound healing?

Answer 17

• Bacteria destroyed and debris removed
• Macrophages arrive to continue clearing debris and also secrete growth factors and proteins that attract immune system cells to the wound to facilitate tissue repair
• Lasts 4 to 6 days and is often associated with edema, erythema (reddening of the skin), heat and pain

Question 18

What happens in the proliferative phase of wound healing?

Answer 18

3 distinct stages:

1) filling the wound
2) contraction of the wound margins
3) covering the wound (epithelialization)
- often lasts anywhere from 4 to 24 days

Question 19

What happens during the maturation phase of wound healing?

Answer 19

• New tissue slowly gains strength and flexibility
• Susceptible to interruption due to local and systemic factors, including moisture, infection, and maceration (local); and age, nutritional status, body type (systemic)
• Varies greatly from wound to wound, often lasting anywhere from 21 days to two years

Question 20

Cleaning a wound

Answer 20

Apply noncytotoxic solution
Irrigation- Removes exudate; use sterile technique with syringe
Debridement- Removal of nonviable tissue

Question 21

What are the steps for cleaning a wound?

Answer 21

1. Clean in the direction from 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
   Never use the same piece of gauze twice!

Question 22

What are the different types of wound drainage?

Answer 22

Serous, purulent, serosanguineous, sanguineous

Question 23

What are the aspects of serous drainage?

Answer 23

Clear, watery plasma

Question 24

What are the aspects of purulent drainage?

Answer 24

Thick, yellow, green, tan, or brown

Question 25

What are the aspects of Serosanguineous drainage?

Answer 25

Pale, red, watery: mixture of clear and red fluid

Question 26

What are the aspects of sanguineous drainage?

Answer 26

Bright red: indicates active bleeding

Question 27

Wound bed tissue types: | Granulation

Answer 27

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

Question 28

Wound bed tissue types: | Slough

Answer 28

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

Question 29

Wound bed tissue types: | Eschar

Answer 29

Black or brown necrotic tissue which needs to be removed before would will heal (dead tissue)

Question 30

Complications of wound healing: | What is Hemorrhage?

Answer 30

bleeding (hypovolemic shock), hematoma

Question 31

What do you do if you suspect a wound is infected?

Answer 31

Take a wound culture sample

Question 32

How do you take a wound culture?

Answer 32

- Clean the wound surface with a non-antiseptic (I.e., sterile water or normal saline) solution - Use a sterile swab from a culturette tube - Rotate the swab in 1 cm² of clean tissue in the open wound. Apply pressure to the swab to elicit tissue fluid. Insert the tip of the swab into the appropriate sterile container, and transport to the lab

Question 33

Complications of Wound Healing: | Dehiscence

Answer 33

Partial or total separation of wound layers

Question 34

Complications of Wound Healing: | Evisceration

Answer 34

Protrusion of visceral organs through wound opening

Question 35

Complications of Wound Healing: | Fistulas

Answer 35

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