Wouds: Closures/Assesments/Interventions/Documentation

Question 1

What are the 3 Different Types of Wound Closures?

Answer 1

1. Primary Closure
2. Delayed Primary Closure.
3. Secondary Intention Healing.

Question 2

2 Characteristics of a Primary Closure

Answer 2

1. Clean wound done with in 2-3 days.

2. Sutures stay in for 14 days.

Question 3

2 Characteristics of a Delayed Primary Closure

Answer 3

1. Too contaminated for a primary closure.

2. Closed after a few days.

Question 4

2 Characteristics of a Secondary Intention Healing

Answer 4

1. Soft tissue or skin loss.

2. No closing.

Question 5

1. Explain the Three-Color Concept for Wound Assessment.

2. What are the Three Color Classifications

Answer 5

1. Help classify the level of infection occurring during wound healing.
2. Red, Yellow, and Black

Question 6

Description of the Red Level

Answer 6

An uninfected and well healing wound.

Question 7

3 Physiological Characteristics of the Red Level

Answer 7

1. Definite borders.
2. Granulation Tissue.
3. Apparent Revascularization. (indicated oxygenation is typically present in post-surgical, superficial wounds, and acute burns)

Question 8

3 Intervention Goals for the Red Level.

Answer 8

1. Protect the wound from the environment.
2. Maintain Humidity.
3. Protect wound fluids & new cells.

Question 9

Main Intervention for the Red Level

Answer 9

Cleanse with sterile saline. (or soap and water if cleared by MD)

Question 10

3 Description’s of the Yellow Level

Answer 10

1. Exudate may promote bacterial growth.
2. Macrophages dominate.
3. Delayed healing until infection is under control.

Question 11

3 Intervention Goals for the Yellow Level

Answer 11

1. Facilitate Healing.
2. Continual Cleansing.
3. Removal of non viable tissue.

Question 12

3 Interventions for the Yellow Level.

Answer 12

1. Wash with soap and water.
2. Sterile whirlpools to loosen necrotic tissue once the infection is under control.
3. Wet to dry dressings.

Question 13

Description of the Black Level

Answer 13

Wound is covered with eschar (may have all phases of healing or infection underneath).

Question 14

3. interventions for the Black Level

Answer 14

1. Sterile whirlpool.
2. Work on gentle cleaning (debriding).
3. Use ointments to soften the eschar.

Question 15

What are the 3 Categories You Can Expect to Document for Wound Assessment?

Answer 15

1. Excudate (Fluid from the Wound)
2. Odor,
3. Size of the Wound.

Question 16

3 Documentation Requirements for Exudate

Answer 16

1. Amount (light, moderate, heavy)
2. Type (clear, serosanguineous: “bloody”, purulent: “yellow, puss-like”)
3. Odor (faint. moderate, strong)

Question 17

What Should You do Before Documenting Odor?

Answer 17

Be sure to clean the wound well before assessing odor.

Question 18

What is the expected viability for the 2 types of skin grafts?

Answer 18

1. Split thickness graft 3-5 days (superficial dermis- most common).
2. Full thickness graft 7-10 days (skin and nerve ending)

Question 19

What is a Hypertrophic Scar?

Answer 19

A thickened scar due to the overproduction of collagen, usually genetic.

Question 20

What is the one wound on scar concept?

Answer 20

All the tissue layers scar together. Fibroblast bond all of the layers together into a tight bond.

Question 21

1. What is cellultis?

2. What will you see clinically to assist you in referring the patient to the physician?

Answer 21

1. A sign of infection.

2. Increasing redness around a wound.

Question 22

1. What is lymphangitis?

2. What should you do if this occurs?

Answer 22

1. A red streak is spreading from the wound toward the heart.
2. Call the MD ASAP.

Question 23

What is exudate?

Answer 23

Fluid from a wound.

Can be clear, sanguineous (bloody), purulent (puss-yellow).

Question 24

What is transudate?

Answer 24

The first fluid out of wounds.

Water and electrolytes.