NUR 118 CL - Wounds Care A & B

Question 1

General things to Assess/do

Answer 1

-Palpate
-Odor
-Types of wounds: surgical, pressure, laceration

Question 2

What to assess in peri-wound area? (Tissue surrounding wound)

Answer 2

Temperature, color, dryness, tissue breakdown, bogginess (may indicate spread of ulcer)

Question 3

How would you assess the size?

Answer 3

• Length, width, depth

Question 4

What are types of wound healing (intentions)

Answer 4

Primary intention - Clean wound edges, sutured together (edges are approximated), healing ridge (i.e. surgical wound)

Secondary intention - Wounds that are left open to heal on their own by scar and granulation tissue formation (i.e. pressure ulcer)

Tertiary intention - Surgical wounds that are left open intentionally for 3-5 days to allow edema or infection to diminish

Question 5

Types of Wound drainage

Answer 5

Serous - Clear, watery plasma
-Clean wounds
Sanguineous - Bright red, fresh bleeding
-Fresh bleeding
Serosanguineous - Watery drainage, pale red
-New Wounds
Purulent - Thick Yellow, green or brown drainage
-Infection
Purosanguinous - Red tinged pus & blood
-New wound / infection

Question 6

Describe a Stage 1 Pressure Ulcer

Answer 6

Erythema (reddened skin), intact and non-blanchable (does not blanch when pressed)

Question 7

Describe a Stage 2 Pressure Ulcer

Answer 7

Resembles a blister, dermis exposed, partial thickness skin loss.

Question 8

Describe a Stage 3 Pressure Ulcer

Answer 8

Full-thickness skin loss with crater, adipose tissue visible, slough and/or eschar (dead tissue-black, brown or tan) may be present.
Bone/tendon not visible.

Question 9

Describe a Stage 4 Pressure Ulcer

Answer 9

Full-thickness skin and tissue loss, exposed muscles, tendons, cartilage and bone. Slough and/or escar may be present. Undermining or tunneling may occur.

Question 10

Describe a suspected Deep Tissue Injury (DTI)

Answer 10

Area of skin is INTACT but discolored. May be purplish or deep red, painful, boggy or have blister.

Question 11

Describe an Unstageable Pressure Ulcer

Answer 11

Full-thickness skin and tissue loss that cannot be staged due to a layer of slough or eschar covering the pressure ulcer.
- Eschar or slough are removed by debridement (removal of dead tissue or infected tissue) by a qualified professional

Question 12

What is undermining?

Answer 12

Tissue deteriorating under the edges of the wound in all directions
- Creates pocket-like area

Question 13

What is tunneling?

Answer 13

Tissue erosion extending through subcutaneous tissue or muscle usually in one direction with branching off (tunneling creates channels)

Question 14

Describe Granulation Tissue

Answer 14

Healing tissue, bright red, granular appearance