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Adult Nursing > Wound Care > Flashcards

Wound Care Flashcards

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1
Q

What type of wound is an abrasion?

A

Acute wound

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2
Q

What type of wound is a pressure ulcer?

A

Chronic wound

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3
Q

What is an acute wound?

A

A recently inflicted wound that will usually heal
without problems, providing the appropriate
measures are taken to reduce the risk of infection and
support healing.

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4
Q

Give examples of acute wounds.

A
  • Surgical incisions
  • Lacerations
  • Abrasions
  • Bites and burn injuries
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5
Q

What are the five main functions of the skin?

A
  • Regulation of body temperature
  • Protection
  • Sensation
  • Excretion
  • Synthesis of vitamin D
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6
Q

What are the layers of the skin?

A

Epidermis
Dermis
Subcutaneous Tissue
Fascia
Muscle
Bone

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7
Q

What are the signs and symptoms of inflammation?

A
  • Warmth
  • Swelling
  • Erythema (abnormal redness of skin or mucous membranes)
  • Discomfort
  • Localised
  • Systemically well
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8
Q

What are the signs and symptoms of infection?

A
  • Hot
  • Fluctuant
  • Red
  • Painful
  • Spreading
  • Ascending laryngitis
  • Unwell
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9
Q

What is the correct documentation for a wound injury?

A
  • Time / place of injury
  • Mechanism of injury - how did it happen?
  • Did the wound occur in a clean or dirty
    environment?
  • Any home remedies or first aid treatment?
  • Consider and document tetanus status
  • Examine wound in position of injury
  • Other symptoms; malaise, fever, numbness,
    altered function etc.
  • Patient concerns
  • Clinician concerns
  • Shared decision making
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10
Q

What are the four stages of wound healing?

A
  • Haemostasis
  • Inflammation
  • Proliferation
  • Maturation/remodelling
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11
Q

What is haemostasis?

A

Bleeding is controlled by
clotting – platelets, fibrin and clotting factors are all active.

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12
Q

What is inflammation?

A

Mast cells release histamines and phagocytes start to actively clear area of pathogens.

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13
Q

What is proliferation?

A
  • Collagen fibres develop
    and contraction occurs
  • Epithelial tissue forming
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14
Q

What is maturation/remodelling?

A

Collagen changes and area achieves near normal strength.

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15
Q

What are the extrinsic factors (factors we can control) that influence healing?

A
  • Temperature: Cold delays, heat will cause vasodilation and
    reduce strength.
  • Moisture: Dry or overly moist wounds will not heal.
  • Poor dressing application and
    techniques: Constriction, poor protection, infection.
  • Poor surgical
    technique/presence of
    foreign bodies: Effect of drains, diathermy or contamination.
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16
Q

What are the intrinsic factors (factors we may not be able to control) that influence healing?

A
  • Age: Thinning of epidermis and underlying tissue,
    circulation changes, reduced metabolism.
  • Other medical conditions: Diabetes, cardiopulmonary disease, obesity etc
    can all delay healing.
  • Malnutrition: Causes poor healing, decreased tensile strength, and risk of breakdown.
  • Social factors: Alcohol and smoking, poor mobility, stress,
    isolation, anxiety (deprivation).
  • Medication: Steroids, non steroidal anti‐inflammatories, immunosuppressants.
17
Q

What nutrition does wound healing rely on?

A
  • Protein
  • Energy
  • Micronutrients
18
Q

What are the micronutrients?

A
  • Vitamin C: Functions as an antioxidant, immunity, collagen
    formation, new blood vessels, Fe
    absorption. Found in: Citrus, fruits, leafy veg, tomatoes.
  • Vitamin A: Increases inflammatory response, collagen formation. Found in: Dairy, fish, red fruits, dark green leafy veg.
  • Vitamin E: Used for the immune system, antioxidant. Found in: Broccoli, spinach, eggs,
    wheatgerm.
  • Zinc: Used for collagen synthesis and tissue growth and immune function. Found in: Meat, pulses, wholegrains,
    eggs.
  • Iron: Oxygen carrier, deficiency impairs collagen. Found in: Red meat, green leafy veg,
    dried fruit, fortified cereal.
19
Q

What should you look for in the assessment of wounds?

A
  • Appearance
  • Exudate (fluid that leaks out of blood vessels into nearby tissues)
  • Surrounding tissue
20
Q

What do you look for in the appearance of wounds?

A

◦ Colour
◦ Tan, grey or yellow - devitalised slough; Dark brown – eschar
◦ Signs of healing, scarring or malformed edge

21
Q

What do you look for in the exudate in wounds?

A
  • Colour
  • Amount
  • Consistency
22
Q

What do you look for in the surrounding tissue of a wound?

A
  • Redness
  • Swelling
  • Warmth
  • Maceration (occurs when skin is in contact with moisture for too long. Macerated skin looks lighter in color and wrinkly. It may feel soft, wet, or soggy to the touch)
23
Q

What are the different wound healing products?

A

*Gauze
*Transparent film
*Hydrogels and Hydrocolloids
*Foams
*Calcium Alginate
*Collagen (temporary skin)

Adult Nursing (23 decks)

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