wound care

Question 1

who are at risk of pressure injuries

Answer 1

older adult
diabetics
incontinent people

Question 2

types of wounds

Answer 2

pressure injuries

damage to the skin on bony prominence

Question 3

sites of pressure injuries

Answer 3

heal, skull, back, elbow, buttocks

Question 4

what are some factors or pressure injuries

Answer 4

friction (surfaces rubbing together)
shear (body slides against surface)

Question 5

how do you assess risk factors

Answer 5

timely assessments
braden scale

Question 6

stage 1 pressure injury

Answer 6

intact skin with an area of nonblanchable

Question 7

stage 2 pressure injury

Answer 7

partial thickness loss of the skin
exposed dermis
blister or scrape
pink/red

Question 8

stage 3 pressure injury

Answer 8

full thickness loss of skin
exposed fat and epibole (rolled edges)
undermining (hollow space between intact skin)
tunnel (narrow you can stick init)

Question 9

stage 4 pressure injury

Answer 9

full thickenss and tissue loss
exposed skin, muscle, tendon, or bone

Question 10

darker skin tone

Answer 10

check for temp and edema
look at axillary and compare to the regular skin tone

Question 11

debriedment

Answer 11

removing dead tissue and skin cells
prolongs inflammatory phase

Question 12

unstageable pressure injury

Answer 12

often black where you can’t see under it

Question 13

deep tissue injury

Answer 13

blood-filled blister
intense prolongedpressure
assess to see the actual problem

Question 14

MDRPI

Answer 14

devices applied for diagnostic

Question 15

MARSI

Answer 15

skin injuries occur 30 min after device is removed

Question 16

what are some strategies to prevent pressure injuries

Answer 16

rotate client
hydration
keep skin dry
use cusion to elevate

Question 17

abrasion

Answer 17

scrape

Question 18

puncture

Answer 18

nail in skin but not all the way

Question 19

contusion

Answer 19

break in the skin

Question 20

hematoma

Answer 20

blood vessel breaks

Question 21

acute wound

Answer 21

rapid
edges are straight
goes together in a clean cut

Question 22

chronic wound

Answer 22

over time
stays open for extended time

Question 23

partial thickness wound

Answer 23

wounds are shallow (scrape/abrasion)
healing time 4-7 days
inflammatory, epithelial, reestablishment

Question 24

full thickness wound

Answer 24

painful stage 3 or 4
heals by scar tissue
4 phase

Question 25

describe the phases of a full thickness wound

Answer 25

1. hemostasis: vasoconstriction
2. inflammatory: WBC come
3. proliferative: new tissue forms
4. maturation: remodel and scarring

Question 26

what is some nutrition for wound healing?

Answer 26

protein, zinc, vitamins