Wound Care

Question 1

Principles of wound healing

Answer 1

• intact skin is the first one a defense against microorganisms
• carful hand hygiene is used in caring for a wound
• the body responds systematically to trauma of any of its parts
• adequate blood supply is essential for normal body response to injury
• Normal healing is promoted when the moon is free of foreign materials
• extent of damage and the persons state of health affect wound healing
• Response to wound is more effective and proper nutrition is maintained

Question 2

Health status that delay wound healing

Answer 2

Corticosteroids and postoperative radiation therapy

Question 3

Tissue repair

Answer 3

1) primary intention
- best healing
- clean, surgical incision

2) secondary invention
- edges do not close, heals from inside out
- jagged edge, no surgery, takes longer

3) tertiary intention
- delay in surgical suturing, but is eventually sutured
- May have an infection that needs draining before canned suture

Question 4

Phases of wound healing

Answer 4

1) Hemostasis
2) inflammatory
3) proliferation, reconstruction, or granulation phase
4) maturation or wound remodeling phase

Question 5

Hemostasis

Answer 5

• occurs immediately after initial injury
• involved blood vessels constrict and blood clotting begins
• exudate is formed, causing swelling and pain
• increased perfusion results in heat and redness
• platelets stimulate other cells to migrate to the injury to participate in other phases of healing

Question 6

Inflammatory phase

Answer 6

• follows Hemostasis and last about 4-6 days
• WBC move to wound
• macrophages enter area and remain for an extended period
  • they ingest debris and release growth factors that attract fibroblast to fill in the wound
• generalized body response

Question 7

Proliferation phase

Answer 7

• begins within 2-3 days of injury and may last up to 2-3 weeks
• New tissue is built to fill the wound space through the action of fiber blast
• capillaries grow across the wound
• thin layer of epithelial cells form across the wound
• granulation tissue forms the foundation for scar tissue development

Question 8

Maturation or remodeling phase

Answer 8

• final stage; begins about 3 weeks, months and up to 2 years after injury
• collagen is remodeled
• new collagen tissue is deposited
• scar becomes a flat, thin, white line

Question 9

Local factors affecting wound healing

Answer 9

Pressure 
Desiccation ( dehydration)
Maceration (over hydration)
Trauma
Edema 
Infection 
Excessive bleeding 
Necrosis ( death of tissue)
Presence of biofilm ( thick grouping of micro organisms)

Question 10

Wound dehiscence

Answer 10

Wound separate

Question 11

Evisceration

Answer 11

Protrude out

Question 12

Assessment of wound drainage

Answer 12

Serous- clear
Sanguineous- contain RBC, fresh blood, full thickness wound
Serosanguinous- thin, watery, pale, red-pink color
Purulent- contain pus, cloudy, yellow- tan color

Question 13

Exudate

Answer 13

Accumulation of fluid, dead tissue cells, WBC

Question 14

Wound assessment

Answer 14

• inspect for sight and smell
• palpating for appearance, drainage, and pain
• types of exudate/ drainage
• sutures, drains or tubes and manifestation of complications

Question 15

Presence of infection

Answer 15

• wound is swollen
• wound is deep red in color
• wound feels got on palpation
• drainage is increased and possibly purulent
• foul odor
• edges may be separated, with dehiscence present

Question 16

Factors affecting the response to hot and cold treatment

Answer 16

• method and duration
• degree of heat or cold
• patients age / physical condition
• amount of body surface covered

Question 17

Effects of applying heat

Answer 17

• dilates peripheral blood vessels
• increase tissue metabolism
• reduce blood viscosity and increase capillary permeability
• reduce muscle tension
• helps relieve pain

Question 18

Effects of applying cold

Answer 18

• constructs peripheral blood vessels
• reduces muscle spasms
• promote comfort

Question 19

C diff

Answer 19

• seen largely in older adults
• symptomatic and asymptomatic reservoir
• prolonged antibiotics kill “ helpful” bacteria in intestine the c diff grows
• watery diarrhea, fever, abnormal cramps

Question 20

Preventing c diff

Answer 20

• avoid use of hard to clean equipment
• disinfect care items between patients
• PPE
• hand hygiene- soap and water, not killed by alcohol
• keep environment clean
• educate health care provider

Question 21

Multi drug resistant organisms

Answer 21

• prevent infections, thereby preventing the spread of resistance
• Tracking
• improving antibiotic prescribing/stewardship
• develop new drugs and diagnostic test

Question 22

Airborne precautions

Answer 22

• infection spread via air( TB, rubeola, varicella)
• Private room
• monitor negative air pressure
• 6-12 Air changes per hour
• monitored filtration if air recirculated
• door closed, patient stays in your room
• if the patient comes out of room must have on surgical mask

Question 23

Droplet precautions

Answer 23

• spread in large droplets
• private room if available door may be open
• if patient must come out room must wear surgical mask
• PPE and keep visitors 3 feet from patient

Question 24

Contact precautions

Answer 24

• spread by direct or in direct contact with patient or patient’s environment
• used with multi drug resistant organisms
• limit movement out of the room
• avoid sharing patient care equipment