Sterile Dressings

Question 1

What is a Stage I wound?

Answer 1

Non-blanching erythema or redness that remains visible for more than 30 minutes

Question 2

What is a Stage II wound?

Answer 2

Partial thickness; loss of the epidermal skin layer, possible loss of dermis but not through the dermis

Question 3

What is a Stage III wound?

Answer 3

Full thickness; loss through dermis and into the hypodermis but not through the hypodermis

Question 4

What is a Stage IV wound?

Answer 4

Tissue loss through the hypodermis

Question 5

What are the three stage of wound healing?

Answer 5

1. Inflammatory phase
2. Proliferative phase
3. Remodeling phase

Question 6

What are the three types of wound healing?

Answer 6

1. Primary intention
2. Secondary intention
3. Tertiary intention

Question 7

What is primary intention?

Answer 7

A process that closes the edges of a wound with little or no inflammatory reaction (little or no scar)

Question 8

What is secondary intention?

Answer 8

Healing by granulation or indirect union

- granulation tissue is formed to fill the gap between the edges of the wound with a thing layer of fibrinous exudate

Question 9

What is tertiary intention?

Answer 9

Delayed wound healing

• occurs in the base of ulcerated or cavitary wound
• especially after infection
• wound fills very slowly with granulation tissue and often forms a large scar

Question 10

Describe serous drainage

Answer 10

Clear or yellow tinged plasma like fluid

Question 11

Describe serous sanguineous drainage

Answer 11

Thing watery red drainage

Question 12

Describe sanguineous drainage

Answer 12

Bright red blood

Question 13

Describe purulent drainage

Answer 13

Green or yellow drainage

Question 14

What are some factors that influence the healing of an incision?

Answer 14

1. Age
2. Nutrition
3. Circulation
4. Blood counts (Hct < 33% impairs tissue repair)
5. Smoking
6. Chronic illness
7. Drug therapy
8. Steroids
9. Cortisone
10. Chemotherapy
11. Wound infection
12. Wound environment

Question 15

Why do steroids affect wound healing?

Answer 15

Steroids slow collagen synthesis

Question 16

How does cortisone affect wound healing?

Answer 16

Depresses fibroblast activity and capillary growth

- impair phagocytosis by WBCs

Question 17

How does chemotherapy affect wound healing?

Answer 17

Depresses bone marrow production of WBCs and impairs immune function

Question 18

How does a wound infection affect wound healing?

Answer 18

Prolongs the inflammatory response and the microorganisms use nutrients and oxygen that are intended for repair

Question 19

What are some complications of wound healing?

Answer 19

• Hemorrhage
• Hematoma
• Infection
• Dehiscence
• Evisceration
• Fistula formation

Question 20

What is a hematoma?

Answer 20

A solid swelling of clotted blood within the tissues

Question 21

What is dehiscence?

Answer 21

Wound ruptures along a surgical incision

Question 22

What is evisceration?

Answer 22

Protrusion of the internal organs through an incision

Question 23

What is a fistula formation?

Answer 23

An abnormal tube-like passage from a normal cavity or tube to a free surface or to another cavity

Question 24

What do you need to look for/at when assessing a wound?

Answer 24

• type of wound
• length of incision
• amount of bleeding
• dehiscence?
• redness, swelling, pain
• hematoma?
• smell?
• drains?

Question 25

What do you need to do before you clean a wound or change a dressing?

Answer 25

• check the orders
• offer pain meds
• offer bathroom break
• ensure patient has no tests
• gather all necessary materials

Question 26

What is a partial-thickness wound?

Answer 26

Shallow and involve the loss of the epidermis and partial loss of the dermis

Question 27

What is a full thickness wound?

Answer 27

Extend into the dermis and heal by scar formation

Question 28

If you had to clean an incision site, a penrose drain, and a nephrostomy tube, what order would you clean them in?

Answer 28

1. Incision site
2. Nephrostomy tube
3. Penrose drain