Wound Care

Question 1

Primary Intention Healing

Answer 1

Occurs when surfaces have been closed. Example would be an incision that is sutured closed.

Question 2

Approximated

Answer 2

Closed. To close.

Question 3

Dehiscence

Answer 3

The bursting open of a previously closed wound.

Question 4

Debridement

Answer 4

The process of removing necrotic tissue.

Question 5

Eschar

Answer 5

A scab or dry crust that can form over damaged skin.

Question 6

Should eschar be debrided?

Answer 6

Wet eschar should be removed. Dry/hard eschar should be left alone.

Question 7

What is the benefit of larval therapy?

Answer 7

Maggots secrete digestive enzymes that break down necrotic tissue/bacterial growth and leave healthy tissue untouched.

Question 8

Preferred dressings for deep exudate wounds?

Answer 8

Alginate, foam, and iodine dressings.

Question 9

Why is Granulex sometimes used to prep stage 1 wounds?

Answer 9

Preserves skin integrity, increases blood supply.

Question 10

Benefits of Hydrocolloid dressings/duederm, tegaderm?

Answer 10

They allow oxygenation to the wound, but are not permeable to moisture or bacteria.

Question 11

How does wet to dry dressings debride?

Answer 11

Packing a wound with wet material, allowing it to dry and adhere to nectroic tissue, and removing the dry packing along with the tissue that has adhered. ouch.

Question 12

Enzymatic debridement

Answer 12

Santyl, can aid in the removal of necrotic tissue or infection.

Question 13

wound VAC

Answer 13

Creates neg. pressure. Reduced edema, increases oxygenation, decrease bacteria, promotes the granulation process.

Question 14

Maceration

Answer 14

Tissues softened by prolonged wetness or soaking.

Question 15

Key measures to prevent pressure injury

Answer 15

nutrition, skin hygiene, protection, repositioning, and supportive devices

Question 16

Describe a stage 1 pressure injury

Answer 16

nonblanchable erythema of intact skin. May be sore or feel warm.

Question 17

Describe a stage 2 pressure injury

Answer 17

partial thickness skin loss. Shallow, open ulcers with pink or red wound bed. May present as blisters.

Question 18

Describe a stage 3 pressure injury

Answer 18

Full thickness skin loss. Damage or necrosis of subcutaneous tissue is visible. Slough or eschar may be present.

Question 19

M in m.e.a.s.u.r.e.m.e.n.t

Answer 19

Length, width, depth, area

Question 20

E in m.e.a.s.u.r.e.m.e.n.t

Answer 20

Exudate, quantity and quality

Question 21

A in m.e.a.s.u.r.e.m.e.n.t

Answer 21

Appearance, what’s it look like? Tissue type?

Question 22

S in m.e.a.s.u.r.e.m.e.n.t

Answer 22

Suffering? Pain?

Question 23

U in m.e.a.s.u.r.e.m.e.n.t

Answer 23

Undermining. Pockets around wound under skin.

Question 24

R in m.e.a.s.u.r.e.m.e.n.t

Answer 24

Re- evaluate. Monitor all parameters.

Question 25

E in m.e.a.s.u.r.e.m.e.n.t

Answer 25

Edge condition around wound

Question 26

Granulation

Answer 26

Red, firm, pebbled. Crumbly may indicate infection.

Question 27

Fibrin

Answer 27

Yellow, Firm, and may represent collagen,

Question 28

Slough

Answer 28

yellow, grey, green, loose.

Question 29

Serous exudate

Answer 29

Thin, water, clear to yellow. Odorless

Question 30

Serosanguineous

Answer 30

some blood, pink

Question 31

Sanguineous

Answer 31

blood. bright. not good.

Question 32

seropurulent

Answer 32

thick, watery, white, foul odor. not good

Question 33

purulent

Answer 33

thick. white, creamy, foul odor, not good.

Question 34

When should you not debride eschar?

Answer 34

When it is stable, hard, dry, and intact.