wound care

Question 1

how can wounds be classified?

Answer 1

1. the underlying cause
2. the duration of healing
3. depth of tissue affected

Question 2

what is a superficial wound?

Answer 2

only the epidermis is involved

Question 3

what is a partial-thickness wound?

Answer 3

wound extends into the dermis

Question 4

what is a full-thickness wound?

Answer 4

extends to the deepest layer of tissue involving the subcutaneous tissue and sometimes even the fascia and underlying tendons such as muscle, tendon or bone

Question 5

explain haemostasis in wound healing

Answer 5

hemostasis is the rapid response to physical injury and is necessary to control bleeding. involves vasoconstriction, platelet response and biochemical response

Question 6

what is tissue repair and regeneration in wound healing?

Answer 6

involves 3 phases:

1) inflammation phase (0-4 days):
2) reconstruction phase (2-24 days)
3) maturation phase (24 days - 1 year)

Question 7

explain the inflammation phase of wound healing

Answer 7

body’s normal response to injury. activates vasodilation leading to increased blood flow causing heat, redness, pain, swelling and loss of function. wound exudate may be present and this is also normal body response

Question 8

explain reconstruction phase (proliferation) of wound healing

Answer 8

the when the wound is healing. the body makes new blood vessels, which cover the surface of the wound. this phase includes reconstruction and epithelialization. wound becomes smaller as it heals

Question 9

explain the maturation phase of wound healing

Answer 9

the final phase, when scar tissue is formed. wound is still a risk and should be protected where possible

Question 10

what are some factors delaying wound healing?

Answer 10

• nutrition deficiency, inadequate blood supply, smoking, corticosteroids, infection, anemia, advance age, obesity, diabetes, poor overall health, friction over wound, cold temperatures, excessive moisture

Question 11

what are contractures?

Answer 11

contraction is a part of the healing process; however, it can become excessive resulting in a deformity or contracture. shortening of muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation (more common in burns)

Question 12

what is dehiscence?

Answer 12

separation of previously joined wound edges due to infection, weakness of granulation tissue from a fluid pocket between the tissue layers or obesity

Question 13

what is evisceration?

Answer 13

occurs when wound edges separate to the extent that intestines protrude through the wound

Question 14

what is excess granulation?

Answer 14

excessive tissue growth that interferes with epithelialization and wound healing

Question 15

what is a fistula?

Answer 15

abnormal passage that forms between organs or hollow organ and the skin

Question 16

what is involved in a wound assessment?

Answer 16

type of wound, etiology of wound, location and appearance of surrounding skin, tissue loss, appearance of the wound bed, stage of healing, measurement and dimensions, exudate, presence of infection and pain

Question 17

what is exudate?

Answer 17

it is produced by all acute and chronic wounds as part of the natural healing process. it contains nutrients, energy and growth factor for cells, has high quantities of WBCs, cleanses the wound, maintains a moist environment and promotes epithelialisation

Question 18

what are signs of infection in a wound?

Answer 18

redness
exudate
localised heat
edema

Question 19

what is primary intention of healing?

Answer 19

healing occurs when margins of the wound fit neatly together

Question 20

what is secondary intention of healing?

Answer 20

healing occurs when wounds have wide or irregular margins that can’ be approximated

Question 21

what is tertiary intention?

Answer 21

healing occurs when a wound is intentionally left open because if it is closed, contamination may be trapped, edema may be present or there is poor circulation

Question 22

what is the goal of wound cleansing?

Answer 22

remove visible debris and devitalised tissue, remove dressing residue
remove excessive or dry crusting exudate
reduce contamination

Question 23

what are the principles of wound cleansing?

Answer 23

aseptic technique, cleanse in a way that minimized trauma, cleanse the wound using an irrigation method

Question 24

when is gauze used?

Answer 24

on infected wounds, wound that require packing, wounds that are draining, wounds needing frequent dressing changes

Question 25

what are the pros and cons of gauze?

Answer 25

pros: conforms to the wound well, can stay in place for a week, prevents friction against wound bed, keeps wound bed dry and prevents bacterial contamination of the wound
cons: may stick, not suitable for heavy draining

Question 26

what are foam dressings?

Answer 26

they are non-occlusive and less likely to stick to wound beds

Question 27

what are pros and cons of foam dressings?

Answer 27

pros: comfortable, won’t stick to wound bed, highly absorbent
cons: may require a secondary dressing to hold the foam in place, if not changed enough can promote periwound maceration

Question 28

what are hydrocolloid dressings?

Answer 28

very absorbent, contains colloidal particles that swell into a gel-like mass when they come in contact with exudate. promotes debridement, provides insulation to the wound bed, is waterproof and impermeable to bacteria, urine and stool.

Question 29

what are the pros and cons of hydrocolloid dressings?

Answer 29

pros: encourages autolytic debridement, provides insulation to the wound bed, waterproof and impermeable to bacteria, urine, stool
cons: leave a residue present in the wound bed which may be mistaken for infection

Question 30

what are hydrocolloid dressings used for?

Answer 30

burns, pressure ulcers, venous ulcres

Question 31

what are foam dressings used for

Answer 31

pressure ulcers, minor burns, skin grafts, diabetic ulcers, venous ulcers

Question 32

what are alginates dressing?

Answer 32

extracted from seaweed. form a gel when they come in contact with exudate. can be used when infection is present

Question 33

what are alginate dressings used for?

Answer 33

venous ulcers, wounds with tunneling, wounds with heavy exudate

Question 34

what are the pros and cons of alginates dressings?

Answer 34

pros: highly absorbent, may be used when infection is present, non-adherent, encourage autolytic debridement
cons: always require a second dressing, may cause desiccation of the wound bed, as well as drying exposed tendon, capsule or bone