Wound Assessment

Question 1

what are the phases of healing

Answer 1

1) hemostasis
2) inflammation
3) proliferation, granulation, contracture
4) remodeling

Question 2

what are a big component of hemostasis

Answer 2

platelets

Question 3

what are a big component of inflammation

Answer 3

neutrophils

Question 4

what are a big component of proliferation, granulation and contracture

Answer 4

macrophages, lymphocytes, angiocytes, fibroblasts, keratinocytes

Question 5

what are a big component of remodeling

Answer 5

fibrocytes

Question 6

what impairs wound healing

Answer 6

Medications
Immunosuppression
Chronic conditions such as DIABETES and peripheral arterial disease
Infection
Poor hygiene
Malnutrition

Question 7

when should wound assessment be done

Answer 7

regularly

Question 8

when should diabetics assess their feet and what should they wear

Answer 8

diabetics should assess their feet DAILY and wear appropriate footwear (socks and shoes).

Question 9

what do you FIRST attain in wound assessment

Answer 9

HISTORY

Question 10

what is the second thing attained in would assessment

Answer 10

etiology

Question 11

what questions do you ask for etiology

Answer 11

Is the wound surgical or nonsurgical? Is it acute or chronic?

Question 12

describe chronic wounds

Answer 12

fail to follow the orderly (and timely) process of healing

Question 13

what is the third part of wound assessment

Answer 13

determine wound location, depth and size

Question 14

what is wound size and depth measured in

Answer 14

cm

Question 15

what is the fourth part of wound assessment

Answer 15

Exudate amount and consistency

Question 16

yellowish fluid with small amounts of blood

Answer 16

serosanguineous

Question 17

fluid containing mostly blood

Answer 17

sanguineous

Question 18

what is the fifth part of wound assessment

Answer 18

Document tunneling or undermining

Question 19

narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation.

Answer 19

tunneling wound

Question 20

occurs when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound’s edge

Answer 20

wound undermining

Question 21

what is the sixth part of wound assessment

Answer 21

Describe the appearance of the wound bed

Question 22

reddish new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process

Answer 22

granulation tissue

Question 23

dead or devitalized tissue.

Answer 23

necrotic tissue

Question 24

a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite, or as a result of anthrax infection.

Answer 24

eschar

Question 25

how would you describe the appearance of the wound bed

Answer 25

What color is the wound tissue? | Granulation tissue, necrotic tissue, eschar

Question 26

what is the seventh part of wound assessment

Answer 26

Describe the peri-wound skin (the skin surrounding the wound)

Question 27

what is the eighth part of wound assessment

Answer 27

Pain or odor?

Question 28

what can be a source of abscess

Answer 28

Tissue destruction underlying intact skin that results in dead space

Question 29

involves large portion of the wound edge

Answer 29

undermining

Question 30

narrow, involves small amount of wound edge and may have significant length

Answer 30

tracts/tunnels

Question 31

dead tissue, usually cream or yellow in colour

Answer 31

slough

Question 32

signs and symptoms of wound infection

Answer 32

``` Odor Purulent exudate Erythema Edema of the surrounding skin Increased pain (or new report of pain) Friable wound tissue Wound depth extends to the bone (osteomyelitis) Increased wound size or a delay in healing ```

Question 33

Wound depth extends to the bone

Answer 33

osteomyelitis

Question 34

what method should you use to measure a wound on a patient

Answer 34

clock method to measure, with 12 o’clock being the patient’s head and 6 o’clock oriented to the patient’s feet

Question 35

how do you measure wound depth

Answer 35

by inserting a sterile swab into the deepest area of the wound. Place a gloved forefinger on the swab at skin level.

Question 36

what is important to remember when measuring a wound

Answer 36

Take 2 or 3 measurements to ensure that you are correct!

Question 37

what are the causes of diabetic foot ulcers

Answer 37

Peripheral arterial disease Neuropathy Callus formation Musculoskeletal (foot) deformities

Question 38

localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear

Answer 38

pressure ulcer

Question 39

stage 1 pressure ulcer

Answer 39

INTACT skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue

Question 40

stage 2 pressure ulcer

Answer 40

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister.

Question 41

stage 3 pressure ulcer

Answer 41

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Question 42

stage 4 pressure ulcer

Answer 42

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. May include undermining and tunneling.

Question 43

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Answer 43

deep tissue injury

Question 44

describe deep tissue injury signs

Answer 44

painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Question 45

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough or eschar in wound bed

Answer 45

unstageable pressure ulcer

Question 46

what is the pressure ulcer prevention methods

Answer 46

``` Identify risk factors Identify patients at risk for pressure ulcers Skin Care Nutrition Mechanical Loading Support Surfaces Education ```

Question 47

senses that are typically impaired

Answer 47

•Visual•Hearing•Olfactory ad gustatory•Balance disorder

Question 48

what language should be used for people with disablities

Answer 48

•Put the person before the disability•Describe what the has, not who the person is

Question 49

best way to communicate if deaf

Answer 49

•Sign•Lip read•Write notes

Question 50

most commonly administered in an institution professional medical caregivers no time restriction life prolonging therapy is not avoided

Answer 50

palliative care

Question 51

more numerous commonly administered at home MUST be considered terminal focus on COMFORT not treatment

Answer 51

hospice care