Principles of Wound Care

Question 1

Angiogenesis

Answer 1

Formation of new granulation, vessels form from pre-existing vessels

Question 2

Colonization

Answer 2

Presence of bacteria with no signs of infection

Question 3

Acute wound

Answer 3

Heals uneventfully within expected time fram

Question 4

Chronic wound

Answer 4

Underlying pathophysiology causes the wound or interferes with the course of healing

Question 5

Primary Intention

Answer 5

Surgical Wound

Question 6

Secondary intention

Answer 6

Wound edges are too far apart to be surgically closed,, healing through natural granulation and epithelialization

Question 7

Tertiary intention

Answer 7

Delayed in wound closure resulting in granulation of wound edges, later surgical closure results in more scar formation. Wound may be left open for several days to allow edema and infection to resolve or exudate to drain.

Question 8

Arterial ulcer (aka ischemic ulcer)

Answer 8

1. Insufficient arterial perfusion (DM or PVD)
2. Wound commonly found between toes, phalangeal heads or lateral malleolus.
3. Pallor or cyanosis to limb, punched out appearance

Question 9

Diabetic ulcer

Answer 9

Usually found of the plantar aspect of the foot, heals or metatarsal heads. Even well defined wound margins.

Question 10

Venous ulcers

Answer 10

1. Caused by a disturbance to return blood flow from the legs
2. found on the medial lower leg above the medial malleolus
3. Can be edematous, have dilated veins and lack of pain
4. Irregular wound margins, ruddy granular tissue, moderate to heavy exudate.

Question 11

Deep tissue injury

Answer 11

Purple, maroon or discolored blood blister, painful firm or mushy.

Question 12

Stage 1 pressure ulcer

Answer 12

Intact skin with non-blanchable redness

Question 13

Stage 2 Pressure Ulcer

Answer 13

Partial thickness tissue loss, shallow open wound, pink wound bed with no slough

Question 14

Stage 3 Pressure Ulcer

Answer 14

Full thickness tissue loss, exposed fat but no bone or tendon, may be slough in the wound.

Question 15

Stage 4 Pressure Ulcer

Answer 15

Full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar present

Question 16

Unstageable Pressure Ulcer

Answer 16

Full thickness loss of tissue, base covered with slough or eschar

Question 17

Wound Healing Process

Answer 17

1. Injury
2. Hemostasis
3. Inflammatory phase
4. Proliferative phase
5. Epithelial closure
6. Maturation

Question 18

Hemostasis

Answer 18

Period of vasoconstriction when the body tried to prevent bleeding

Question 19

Inflammatory phase of healing

Answer 19

2-6 days post injury with increased blood flow, heat, redness and swelling.

Question 20

Proliferative phase of healing

Answer 20

Granulation and epithelialization begin

Question 21

Hydrogel dressing

Answer 21

Non-adherent dressing composed of water and a polymer with absorbent properties. Treats full to partial thickness wounds that are dry or minimally draining.

Question 22

Foam Dressing

Answer 22

Some absorptive properties, for full or partial thickness wounds, minimal to heavy drainage.

Question 23

Hydrocolloid dressing

Answer 23

Adhesive and moldable wafer for full to partial thickness wounds with minimal or moderate drainage.