Wound Care

Question 0

What are four ways to maintain healthy skin?

Answer 0

SKIN: Support surfaces, Keep moving, Incontinence control, Nutrition

Question 1

What is the largest organ in the body?

Answer 1

The skin

Question 2

How often should you reposition bed bound patients?

Answer 2

Every 2 hours

Question 3

What degree should you position the HOB if a patient is at risk for pressure ulcers?

Answer 3

Less than 30 degrees

Question 4

What are the top three reasons that foleys leak?

Answer 4

1. constipation
2. dehydration
3. uti

Question 5

What are three interventions to prevent dermatitis?

Answer 5

Cleanse (routine daily cleansing for everyone), moisturize (cleanse and moisturize after each major incontinent episode), protect (apply moisture barrier for significant incontinence)

Question 6

What kinds of wounds are stageable?

Answer 6

Pressure ulcers

Question 7

Which stage of pressure ulcers are reportable to State DHS?

Answer 7

Stages III & IV

Question 8

Which assessment tool is used to evaluate a person’s risk for skin breakdown?

Answer 8

Braden scale

Question 9

What does a low number indicate on the Braden scale?

Answer 9

A high risk

Question 10

What does a high number indicate on the Braden scale?

Answer 10

A low risk

Question 11

Define pressure ulcer.

Answer 11

Localized area of tissue breakdown resulting from compression of soft tissue between a bony prominence and an external surface

Question 12

Which bony prominences have the highest incidence of pressure ulcers?

Answer 12

Sacrum and heels

Question 13

Define stage I pressure ulcer.

Answer 13

Non-blanchable erythema of intact skin (may include discoloration, warmth/coolness, edema, change in tissue consistency)

Question 14

Define stage II pressure ulcer.

Answer 14

Partial thickness loss of dermis

Question 15

Define stage III pressure ulcer.

Answer 15

Full thickness skin loss (with or without undermining, eschar/slough may be present, subcut fat may be visible)

Question 16

Define stage IV pressure ulcer.

Answer 16

Full thickness skin loss (with visible or palpable muscle/bone/tendon, may include undermining/sinus tracts)

Question 17

Define unstageable pressure ulcer.

Answer 17

Ulcer bed is covered with eschar or slough so that the full extent of the injury cannot be assessed

Question 18

Define suspected deep tissue injury.

Answer 18

Purple or maroon area of intact skin, or blood filled blister due to damage of underlying tissue. May evolve into ulcer.

Question 19

What are the four cardinal signs of inflammation?

Answer 19

Rubor (redness), tumor (swelling), calor (heat), dolor (pain)

Question 20

Define proliferation.

Answer 20

To grow by rapid production of new cells (first stage of wound healing)

Question 21

Which nursing measures can optimize wound healing preoperatively?

Answer 21

Nutrition, reduce steroids, eliminate aspirin, patient education to reduce anxiety

Question 22

Which nursing measures can optimize wound healing postoperatively?

Answer 22

Pain control, warmth, hydration, oxygenation, support binders

Question 23

Define acute wound.

Answer 23

Wounds with sudden onset including superficial, penetrating, perforating, laceration, abrasion, contusion, skin tear, surgical wound

Question 24

Define chronic wound.

Answer 24

Any acute wound that fails to heal or pressure, venous, arterial, diabetic and neuropathic wounds

Question 25

Define undermining.

Answer 25

Tissue destruction to underlying intact skin along wound edges

Question 26

Define tunneling.

Answer 26

A measurable tract extending from the wound bed

Question 27

Define serous wound exudate.

Answer 27

Clear, watery plasma

Question 28

Define sanguineous wound exudate.

Answer 28

Bright red; indicates active bleeding

Question 29

Define serosanguineous wound exudate.

Answer 29

Pale pink, watery drainage; mixture of clear and red fluid

Question 30

Define purulent wound exudate.

Answer 30

Thick, yellow, green or brown drainage.

Question 31

What might a foul smelling wound indicate?

Answer 31

Infection (or expected in the presence of eschar or slough)

Question 32

What would a red-colored wound indicate?

Answer 32

Usually granulation tissue

Question 33

What would a yellow-colored wound indicate?

Answer 33

Slough (soft-necrotic tissue)

Question 34

What would a black-colored wound indicate?

Answer 34

Eschar (firm/hard necrotic tissue)

Question 35

What is the most basic principle of wound healing?

Answer 35

Keep the wound warm, dark, moist and protected

Question 36

What is the best way to prevent pressure ulcers on the heels?

Answer 36

Float heels

Question 37

How is a wound measured?

Answer 37

Length x width x depth

Question 38

How do you care for a dehisced wound?

Answer 38

Keep it open and pack lightly (must heal from the inside out to prevent an abscess from forming)

Question 39

Which area of the body never gets debrided if it is intact and not infected?

Answer 39

Heels (too thin of tissue, debriding would reveal bone easily)

Question 40

What is wound healing by primary intention?

Answer 40

Wound approximating; healing occurs by epithelialization; wound approximates quickly and with minimal scar formation (ex: staples, sutures)

Question 41

What is wound healing by secondary intention?

Answer 41

Wound not approximating;heals by granulation, wound contraction and epithelialization (ex: pressure ulcers)

Question 42

What is wound healing by tertiary intention?

Answer 42

Closure of wound is delayed to resolve risk of infection, then wound is approximated

Question 43

Why would a wound be debrided?

Answer 43

To rid the wound of source of infection, enable visualization of wound bed, or provide a clean base necessary for healing

Question 44

Normal Values: prealbumin

Answer 44

15-36 mg/dL

Question 45

Normal values: albumin

Answer 45

3.5-5 g/dL