Quiz 2 Flashcards
What are some tissue types you may see in a wound bed? Give a description
- Slough - yellow, clumpy
- Granulation - pink/red, wet
- Epithelial - shiny, new pink tissue
- Necrotic (eschar) - black, leathery, firmly adhered to the wound
T or F? A wound with slough tissue is always infected?
False
Which types of exudate are normal? which are abnormal and possibly infected?
Normal:
- Serous (clear/thin)
- Serosanguineous (red/pink/watery)
- Sanguineous (red/thin/watery)
Abnormal/Infection:
- Purulent (yellow/thick)
- Seropurulent (watery/cloudy/yellow)
- Pseudomonas (blue/green)
What are the 3 lines of defense from pathogens?
1.) Surface/skin barrier
2.) Cellular and chemical defenses (immune cells and inflammatory response)
3.) Specific defense (lymphocytes and antibodies)
What are the 4 levels of infection?
1.) Contamination (microbes on the surface… normal)
2.) Colonization (replicating microbes on surface… normal)
3.) Critical colonization (microbes on surface begin to delay wound healing… abnormal)
4.) Infection (replicating microbes invade body tissues and decline wound status… normal)
What does “impregnated” refer to in terms of wound healing?
The process in which substances are embedded within the skin
What are the signs of inflammation?
Redness (erythema), edema, heat, loss of function, pain
What are the signs of infection?
- Exact same as the inflammation signs, but excessive
- Thick, smelly, green/blue, copious (a lot of) exudate
- Decline in wound status despite appropriate care
- Systemic symptoms like fever and nausea
What are some of the primary purposes of wound dressings?
- Protect from injury
- Provide a moist, warm environment (ideal for wound healing)
- Manage drainage
- Gas exchange
Describe the pulse ratings
0: No pulse
1: Thready pulse (barely there)
2: Weak pulse
3: Normal pulse
4: Pounding/racing pulse
Differentiate between undermining and tunneling
Undermining: Destruction of tissue under the wound edges so the wound is actually bigger than what you can see from the surface
Tunneling: A separation of fascial layers under the skin forming a tunnel deep in an area of a wound
What percent decrease in wound surface area within 2-4 weeks signifies good indication
of wound healing
a. 10-20%
b. 20-40%
c. 40-60%
d. 50-70%
b. 20-40%
A micro-organism is multiplying to the extent that it is impairing wound healing and wound bioburden, what level of infection is it at
a. Contamination
b. Colonization
c. Critical colonization
d. Infection
c. Critical colonization
What is a silent infection?
An infection that does not have noticeable symptoms/signs making it tough to detect
Which patient population are susceptible to silent infections?
The immunocompromised and individuals with inadequate perfusion (restricted blood flow)
What is the difference between inflammed tissue and infected tissue?
Inflammed tissue has well defined borders while infected tissue does not
What is the gold standard for diagnosing a wound infection?
Tissue biopsy
A patient needs to get an MRI but has a wound with an antimicrobial silver dressing on, how should they proceed?
Remove the dressing before the MRI (silver is metal and cannot go in an MRI)
A patient has MRSA, should you use standard or universal precautions?
Standard (contact precautions: gown and gloves)
How long is saline good for once it is opened?
24 hours
What type of environment is ideal for wound healing?
Moist and warm environment
Describe the edema scale ratings
1+ : Indentation is barely visible
2+ : Slight indentation with depression, returns to normal within 15 seconds
3+ : Deeper indentation when pressed, returns to normal in 15-30 seconds
4+ Indentations that last longer than 30 seconds
What is undermining?
Area of destruction under wound edges
What is tunneling?
A passageway of tissue destruction under the skin surface (can turn into sinus tract)