Wound assessment and healing

Question 1

Acute inflammatory phase

Answer 1

Healing occurs in 2 to 3 weeks, usually leaving no residual damage
Neutrophils are predominant cell type at site of inflammation

Question 2

Sub-acute inflammatory phase

Answer 2

Has same features as acute inflammation but persists longer

Question 3

Chronic inflammatory phase

Answer 3

May last for years
Injurious agent persists or repeats injury to site
Predominant cell types involved are lymphocytes and macrophages
May result from changes in immune system (e.g., autoimmune disease)

Question 4

Inflammatory Response

Answer 4

Final phase of inflammatory response is HEALING

Healing has 2 major components
Regeneration
Repair

Question 5

Wound Healing: Regeneration

Answer 5

Replacement of lost cells and tissues with cells of same type
Stable cells regenerate in response to injury
Liver, bone, kidney & pancreas

Constantly dividing cells that rapidly regenerate
Skin, bone marrow, lymphoid organs, mucous membrane cells of urinary, reproductive, and GI tracts

Permanent cells do not divide
Neurons replaced by glial cells or stem cells
Skeletal & cardiac muscle are repaired with scar tissue

Question 6

Wound Healing: Regeneration

Answer 6

Replacement of lost cells and tissues with cells of same type
Stable cells regenerate in response to injury
Liver, bone, kidney & pancreas

Constantly dividing cells that rapidly regenerate
Skin, bone marrow, lymphoid organs, mucous membrane cells of urinary, reproductive, and GI tracts

Permanent cells do not divide
Neurons replaced by glial cells or stem cells
Skeletal & cardiac muscle are repaired with scar tissue

Question 7

Wound Healing: Repair

Answer 7

Repair
Healing as a result of lost cells being replaced with connective tissue
More common than regeneration
More complex than regeneration
Occurs by primary, secondary, or tertiary intention

Question 8

Primary Intention

Answer 8

Initial phase
Lasts 3 to 5 days
Edges of incision are aligned
Blood fills the incision area, which forms matrix for WBC formation
Acute inflammatory reaction occurs
May initially be covered with dry dressing

Granulation phase
Lasts 5 days to 3 weeks
Fibroblasts migrate to site
Wound pink and vascular
Surface epithelium begins to regenerate

Maturation phase & scar contraction
Begins 7-days after injury & continues for several months/years
Fibroblasts disappear as wound becomes stronger
Mature scar forms

Question 9

Secondary Intention

Answer 9

Wounds occurring from trauma, ulceration & infection
Large amounts of exudate
Wide, irregular margins
Extensive tissue loss
Edges cannot be approximated
Results in more debris, cells, exudate
Wound care depends on etiology & type of tissue in wound

Question 10

Tertiary Intention

Answer 10

Delayed primary intention due to delayed suturing of the wound
Example: A contaminated wound left open & sutured closed after infection is controlled

Question 10

Tertiary Intention

Answer 10

Delayed primary intention due to delayed suturing of the wound
Example: A contaminated wound left open & sutured closed after infection is controlled

Question 11

Risks Factors for Delayed Healing

Answer 11

Nutritional deficiencies
Inadequate blood supply
Corticosteroid drugs
Infection
Smoking
Mechanical friction on wound
Advanced age
Obesity
Diabetes mellitus
Poor general health
Anemia

Complications:
Adhesions
Contractures
Dehiscence
Evisceration
Excess granulation tissue
Fistula formation
Infection
Hemorrhage
Hypertrophic scars
Keloid formation

Question 12

Pressure Ulcers

Answer 12

Graded or “Staged” according to deepest level of tissue damage:
Stage I (minor) to Stage IV (severe)
Un-stageable

Slough and/or eschar must be removed for accurate staging
EXCEPTION:
Stable (dry, adherent, intact) eschar on the heels serves as “the body’s natural (biologic) cover” & should not be removed

Question 13

Stage I pressure ulcers

Answer 13

Intact skin
Areas of non-blanchable redness (in lighter skin individuals)
In dark-skinned patients after applying light pressure, look for an area that’s darker than the surrounding skin or that’s taut, shiny, or indurated (hardened)

If you suspect a skin area is becoming damaged, use the light from a camera flash system to enhance your visualization of dark skin; with the patient’s permission, take a series of digital images each day to document changes in wound color, size, and depth. Check for localized changes in skin texture and temperature.

Question 14

Stage I – Dark Skin

Answer 14

Early signs of skin damage include induration, bogginess (less-than-normal stiffness), and increased warmth at the injury site compared to nearby areas. Over time, as tissues become more damaged, the area becomes cooler to the touch.
Possible indicators
Skin temperature
Tissue consistency
Pain
May appear red, blue, or purple in patients with darker skin tones

Question 15

Stage II

Answer 15

Partial-thickness loss of dermis
Shallow open ulcer with red pink wound bed
Presents as an intact or ruptured serum-filled blister
May also present as a blood-filled blister

Question 16

Stage III

Answer 16

Full-thickness skin loss
Damage or necrosis of subcutaneous tissue
May extend to, but not through underlying fascia
Presents as a deep crater with possible undermining
Depth varies by anatomic location

Question 17

Stage IV

Answer 17

Full-thickness loss extending to muscle, bone, or supporting structures
Bone, tendon, or muscle may be visible or palpable
Undermining & tunneling may occur

Slough or eschar may be present on some parts of the wound bed.

Question 18

Stage IV

Answer 18

Full-thickness loss extending to muscle, bone, or supporting structures
Bone, tendon, or muscle may be visible or palpable
Undermining & tunneling may occur

Slough or eschar may be present on some parts of the wound bed.

Question 19

Wound Assessment

Answer 19

Admission skin assessment
On admission from PACU
At regular intervals
Identify factors that may delay healing

Nursing Diagnosis
Impaired skin integrity
Impaired tissue integrity
Risk for infection

Question 20

Wound Assessment

Answer 20

Admission skin assessment
On admission from PACU
At regular intervals
Identify factors that may delay healing

Nursing Diagnosis
Impaired skin integrity
Impaired tissue integrity
Risk for infection

Question 21

Wound Classification

Answer 21

Cause
Surgical or nonsurgical
Acute or chronic
Depth of tissue affected
Superficial, partial thickness, full thickness
Color
Red
Yellow
Black
May have two or more colors

Question 22

Wound Measurement

Answer 22

Made in centimeters
Head to toe
Side to side
Depth (if any)
Tunneling?
Undermining?

Question 23

Tunneling

Answer 23

Movement when cotton-tipped applicator is placed in wound

Question 24

Undermining

Answer 24

Presence of “lip” when cotton-tipped applicator is placed in wound
Charted in respect to a clock with 12 o’clock being toward the patient’s head

Question 25

Wound Documentation

Answer 25

Location
Type
Stage if pressure ulcer
Measurements (Height, width, depth)
Undermining?
Tunneling?
% granulation tissue, slough, eschar?
Drainage (amount, color, quality, odor?)
Dressing / treatment
Patient tolerance, pain?

Question 26

Method of Wound Care Depends On:

Answer 26

Causative agent
Degree of injury
Patient’s condition
Purposes of wound management
Cleansing
Treating infection
Protecting clean wound from trauma

Sutures / fibrin sealant help closure
Drains may be inserted
Topical antimicrobials / antibacterials should be used with caution

Question 27

Nursing Implementation

Answer 27

Red Wounds
Protection
Gentle cleaning PRN
Yellow wounds
Absorb exudate
Cleanse wound surface
Hydrocolloid dressings
Black Wounds
Debridement of nonviable tissue (“Eschar”)

Question 28

Types of Debridement

Answer 28

Surgical

Mechanical
Wet-to-dry (moist) dressings
Irrigation
Whirlpool

Autolytic
Semi-occlusive
Occlusive
Transparent films
Hydrocolloids (Duoderm)

Enzymatic
Topical application of enzyme ointments / creams
Covered with moist dressing
Collagenase (Santyl)
Papain / Urea (Panafil)

Question 29

Types of Debridement

Answer 29

Surgical

Mechanical
Wet-to-dry (moist) dressings
Irrigation
Whirlpool

Autolytic
Semi-occlusive
Occlusive
Transparent films
Hydrocolloids (Duoderm)

Enzymatic
Topical application of enzyme ointments / creams
Covered with moist dressing
Collagenase (Santyl)
Papain / Urea (Panafil)

Question 30

Negative Pressure Wound Therapy

Answer 30

Vacuum-assisted closure
“Wound VAC” (K.C.I.)
Suction removes drainage and speeds healing
Monitor:
Serum protein
Fluid & electrolytes
Coagulation studies

Question 31

Negative Pressure Wound Therapy

Answer 31

Vacuum-assisted closure
“Wound VAC” (K.C.I.)
Suction removes drainage and speeds healing
Monitor:
Serum protein
Fluid & electrolytes
Coagulation studies

Question 32

Hyperbaric Oxygen Therapy

Answer 32

Delivery of 100% oxygen
1.5 to 3 times normal atmospheric pressure
10 to 60 treatments (90 to 120 minutes)
Allows O2 to diffuse into serum
Stimulates angiogenesis
Kills anaerobic bacteria
Increases killing power of WBCs & certain antibiotics
Accelerates formation of granulation tissue

Question 33

Nutritional Therapy

Answer 33

High protein
High carb
High vitamin
Moderate fat

Question 34

Psychological Implications

Answer 34

Fear of scar / disfigurement
Concern about drainage or odor

Question 35

Infection Prevention/Control

Answer 35

Don’t touch recently injured areas
Keep environment free of possibly contaminated items
Prophylactic antibiotics?
Wound cultures - Concurrent swab specimens obtained from wound exudate

Question 36

Z-technique

Answer 36

Rotate swab as wound is swabbed margin to margin in a 10-point zigzag

Question 37

Levine’s technique

Answer 37

Rotate swab over a 1cm² area with sufficient pressure to express fluid