Unit 6: Wound Care

Question 1

Healthy People 2010 Initiative?

Answer 1

Goal of 50% reduction of pressure ulcer incidence by 2010.

Question 2

What is Stage 1 of a Pressure Ulcer?

Answer 2

Skin is intact. Redness.

Question 3

What is Stage 2 of a Pressure Ulcer?

Answer 3

Partial thickness–partial dermis loss. Appears as shallow ulcer or blister.

Question 4

What is Stage 3 of a Pressure Ulcer?

Answer 4

Full thickness wound. Subcutaneous tissue visible.

Question 5

What is Stage 4 of a Pressure Ulcer?

Answer 5

Full thickness wound with exposed bone, tendon, or muscle.

Question 6

If wounded tissue is black, what may be the cause?

Answer 6

Black tissue caused by Necrotic tissue (tissue death)

Question 7

What are the different types of Wound Closures?

Answer 7

Primary Intention Closure:
* Utilized if minimal skin loss & able to be sutured together.

Secondary Intention Closure:
* No sutures–healed by connective tissue
* Wound edges are large, open, full thickness

Delayed Primary Closure/Tertiary Intention Closure:
* Left open initially–sutured later.
* Used if wound gets infected.

Question 8

Burn Classifications?

Answer 8

First Degree:
* Epithelial layer

Second Degree:
* Dermal layer

Third Degree:
* Full thickness–Dermis destroyed

Fourth Degree:
* Full thickness–prolonged thermal contact

Question 9

Wound Healing Phases?

Answer 9

Inflammatory Phase (–5 days)

Proliferative Phase (2 days–6 weeks)
–Granulation tissue forms/Fibroplasia

Remodeling Phase (6 weeks–2 years)
–New collagen forms…Scar remodeling.
–Tensile strength increases up to 80% of original strength in 2 years

Question 10

Whirlpool setup?

Answer 10

• Water temp of 92º–96ºF
• Treatment duration 10–20 minutes

Question 11

What is the Pulsed Lavage?

Answer 11

Device that delivers pressurized water/saline directly to the wound & uses suction/negative pressure to remove contaminated water.

Pressure: 4–15psi

Question 12

If burns develop Necrotic Tissue, what’s next?

Answer 12

Immersion or non-immersion hydrotherapy.
* Pain management (analgesics) may be necessary

Question 13

Hydrotherapy Contraindications?

Answer 13

• Wound maceration (wet, wrinkly skin)
• Bleeding

For Full Body Immersion:
* Cardiac instability
* Infection that can spread in water
* Urinary/Bowel incontinence
* Severe epilepsy
* Suicidal patients

Question 14

Negative Pressure/Vacuum-Assisted Wound Therapy duration?

Answer 14

6 weeks to as long as 16-20 weeks depending on size of wound.

Question 15

Negative Pressure Wound Therapy Contraindications?

Answer 15

• Presence of necrotic tissue
• Malignancy
• Untreated osteomyelitis
• Over exposed arteries, veins, nerves, or organs
• Over a fistula (abnormal connection between organs)