Wound Assessment and Care

Question 1

haemostasis

Answer 1

blood vessels constrict to stop bleeding, forming clots

Question 2

proliferation

Answer 2

wound is rebuilt with connective tissue to promote granulation and repair wound

Question 3

remodelling

Answer 3

epithelial tissue forms in a moist healing environment

Question 4

acute wound

Answer 4

occurs suddenly and progresses through healing stages as expected

Question 5

chronic wound

Answer 5

wound that fails to progress or progresses slowly through healing stages

Question 6

surgical wound

Answer 6

wound secondary to surgical intervention

Question 7

epithelial tissue

Answer 7

appears pink or pearly white
wrinkles when touched
final stages of healing when wound is covered by healthy epithelium

Question 8

granulating tissue

Answer 8

appears red and moist
occurs when healthy tissue is formed in remodelling phase
well vascularised
bleeds easily

Question 9

slough tissue

Answer 9

appears yellow, brown or grey
devitalised tissue made of dead cells or debris

Question 10

necrotic tissue

Answer 10

appears hard, dry and black
dead tissue preventing wound healing

Question 11

hyper granulating tissue

Answer 11

appears red, uneven or granular
occurs in proliferative phase when tissue is overgrown

Question 12

viable tissue

Answer 12

granulating
epithelial

Question 13

non-viable tissue

Answer 13

necrotic
slough

Question 14

colonisation

Answer 14

microorganisms multiply without provoking a host response

Question 15

local infections

Answer 15

invasion by an agent that may cause injuries

Question 16

treatment for local infections

Answer 16

topical antimicrobial

Question 17

spreading and systemic infections

Answer 17

microorganisms spread from wound to vascular or lymphatic systems impairing healing

Question 18

treatment for spreading and systemic infections

Answer 18

topical microbials and antibiotics to prevent sepsis

Question 19

serous

Answer 19

appears yellow/clear
typical in inflammatory phase
thin and watery drainage

Question 20

haemoserous

Answer 20

appears clear/yellow with pink tinge
typical in inflammatory and proliferative phase

Question 21

sanguineous

Answer 21

common exudate blood
associated with hyper granulation

Question 22

purulent

Answer 22

containing pus
milky/thick in consistency
grey, green or yellow
indicates infection

Question 23

haemopurulent

Answer 23

blood and pus
often due to established infection

Question 24

advancing edges

Answer 24

edges are pink
healing is taking place

Question 25

non-advancing edges

Answer 25

edges are raised, rolled, red or dusky

Question 26

cellulitis

Answer 26

redness
swelling
pain
infection

Question 27

oedema

Answer 27

swelling

Question 28

macerated

Answer 28

soft, broken skin caused by increased moisture