WOUND CARE

Question 1

Acute wound

Answer 1

intentional or uninentional

Question 2

closed wound

Answer 2

no break in skin

Question 3

open wound

Answer 3

break in skin

Question 4

3 conditions associated with chronic wounds

Answer 4

venous disease, arterial disease, neuropathic disease

Question 5

True or false? surgical wounds are acute and intentional.

Answer 5

true.

Question 6

4 classifications of surgical wounds

Answer 6

clean
clean-contaminated
contaminated
dirty

Question 7

What causes moisture-associated skin damage?

Answer 7

skin exposure to irritants

Question 8

can moisture-associated skin damage lead to pressure injuries?

Answer 8

yes

Question 9

combination of friction and pressure commonly associated with Fowler’s positon

Answer 9

shearing forces

Question 10

excoriation

Answer 10

secondary to fecal matter and being wet, exudate, deep skin folds, etc

Question 10

maceration

Answer 10

think of the ceviche, the soaking in acidic fluid caused the food to macerate (cook) except we don’t want our skin to cook

Question 11

3 pressure related factors

Answer 11

pressure intensity, pressure duration, tissue tolerance

Question 12

Stage 1 pressure ulcer

Answer 12

nonblanching, discloration, skin texture and color inconsistent with surrounding skin

Question 13

Stage 2 pressure ulcer

Answer 13

partial thickness skin loss. pink or red tissue viable in wound bed. tissue is moist, deeper tissues are not visible. may have serum-filled blister

Question 13

True or False : stage 2 should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation

Answer 13

true

Question 14

stage 3 pressure ulcer

Answer 14

full-thickness skin loss, visible fat, granulation tissue may be present, wound edges may be rolled, dead tissue may have formed, slough may be present, undermining and tunneling may be present

Question 15

Stage 4 pressure injury

Answer 15

muscle, fascia, tendons, ligaments, cartilage and/or bone is visible

Question 16

Which stage of pressure injury usually requires surgical repair?

Answer 16

4

Question 17

When are DTPI (deep tissue pressure injuries) and ulcers unstageable?

Answer 17

when the base of the wound is not visible due to eschar in the wound bed, when there is a mucosal membrane pressure injury

Question 18

hemostatic/inflammatory phase of wound healing

Answer 18

lasts up to 5 days. exudate and edema should decrease. scab forms protective barrier so that phagocytosis can occur underneath. in a clean wound, this phase establishes a clean wound bed.

Question 19

when can staples be removes?

Answer 19

day 9-14.

Question 20

proliferative phase of wound healing

Answer 20

Granulation tissue matures. vascular bed is re-established. collagen added to injury site to strengthen tissue. from 5 days to 14 days.

Question 21

Maturation/ remodeling phase

Answer 21

begins day 21 and can last over a year. this is where keloids can form in individuals who have an abnormal amount of collagen formation.

Question 22

complications of wound healing

Answer 22

hemorrhage, hematoma, infection, dehiscence, evisceration

Question 23

what to do in the event of evisceration

Answer 23

have client flex knees, cover area with a sterile saline soaked dressing

Question 24

risk factors for dehiscence/evisceration

Answer 24

obesity, poor surgical technique, poor nutrition, mulitple trauma, suture failure, excessive coughing, infection, vomiting, dehydration. mortality rate 30%

Question 25

Wound irrigation : clean or sterile technique?

Answer 25

sterile, required due to break in skin integrity.

Question 26

4 types of wound debridement

Answer 26

mechanical, autolytic, chemical, sharp/surgical