Skin Integrity and Wound Care

Question 1

A wound is defined as:

Answer 1

a break or disruption in the normal integrity of the skin and tissues

Question 2

Closed wound

Answer 2

edges well approximated - no gapping

Question 3

Open wound

Answer 3

Stage 3 or 4 pressure injury
could also be a wound that is intentionally left open for healing

Question 4

Clean wound

Answer 4

typically a surgical wound - use sterile technique

Question 5

Dirty wound

Answer 5

decubitus or pressure injury - use clean technique

Question 6

Incision wound

Answer 6

edges well approximated

Question 7

Contusion wound

Answer 7

bruise

Question 8

Abrasion wound

Answer 8

rubbing or scraping off of the skin’s outer layer

Question 9

Puncture wound

Answer 9

wound caused by a sharp, pointed object piercing the skin

Question 10

Laceration

Answer 10

tear in the skin

Question 11

Partial Thickness

Answer 11

Dermis and epidermis

Question 12

Full thickness

Answer 12

Down to subcutaneous/muscle/bone/tendon

Question 13

Acute wound

Answer 13

Usually heals up in 21 days

Question 14

Chronic wound

Answer 14

can take up to months or years to heal

Question 15

Normal healing of skin requires:

Answer 15

Circulation
Clean environment
Nutrition

Question 16

Primary Intention

Answer 16

closed with suture material

Question 17

Secondary Intention

Answer 17

will heal from wound bed up
Extensive tissue loss
Repair time longer
Scarring is greater
Susceptibility to infection is greater

Question 18

Answer 18

Primary Intention

Question 19

Question 20

Answer 20

Tertiary Intention

Question 21

4 phases of wound healing

Answer 21

Hemostasis
Inflammatory Phase
Proliferation Phase
Maturation or Remodeling Phase

Question 22

Stage 1 of wound healing - hemostasis

Answer 22

blood clotting - usually happens within hours

Question 23

Stage 2 of wound healing - Inflammatory Phase

Answer 23

Red, sore, swollen - usually the first 4 days

Question 24

Stage 3 of wound healing - Proliferation Phase

Answer 24

macrophages move in to clean up wound

Question 25

Stage 3 of wound healing - Maturation or Remodeling Phase

Answer 25

scar formation

Question 26

Types of wound exudate

Answer 26

Serous Serosanguineous Sanguineous Purulent

Question 27

Serous

Answer 27

clear exudate - could be white clear or yellow clear

Question 28

Serosanguineous

Answer 28

pink color

Question 29

Sanguineous

Answer 29

bloody

Question 30

Purulent

Answer 30

pus

Question 31

What is a biofilm?

Answer 31

it prevents topical and systemical antibiotics from working properly - impairs wound healing

Question 32

Hemorrhage

Answer 32

bleeding

Question 33

Dehiscence

Answer 33

wound coming apart *seen mostly from abdominal wounds

Question 34

Evisceration

Answer 34

rips down to underlying organs

Question 35

Fistula

Answer 35

happens when two things that are connected are not supposed to be connected

Question 36

Psychological Effects

Answer 36

body image or self-esteem

Question 37

Factors affecting wound healing:

Answer 37

not enough circulation, oxygenation, or nutrition Obesity Smoking Pressure Desiccation Maceration Medications (Steroids, Aspirin, Antineoplastic) Trauma Edema Infection Necrosis

Question 38

A Braden score of ___ needs a ____ on the sacrum

Answer 38

18; mediplex

Question 39

What cleaning agent is used for ALL wound cleaning?

Answer 39

Normal Saline = .9NS

Question 40

What dressings are EBP for best healing?

Answer 40

wet to moist