wound care

Question 1

acute wound

Answer 1

intentional (surgery) or unintentional (burns, gunshot wounds)

Question 2

lacerations

Answer 2

tears in skin (cuts) due to sharp objects or mechanical forces (ripping tape off skin)

Question 3

wound color changes from?

Answer 3

red–>pink–> pale pink

Question 4

exudate

Answer 4

fluid (plasma) secreted by body during inflammatory stage of healing

Question 5

what is MASD?

Answer 5

moisture-associated skin damage (released when skin is exposed to irritants (pee, poop, sweating)

Question 6

MASD is a form of what?

Answer 6

dermatits

Question 7

what leads to chronic wounds?

Answer 7

(with acute wounds) cond. alter blood flow

Question 8

who is at risk for chronic wounds?

Answer 8

diabetes, peripheral artery disease, immunosuppressed, immobilized

Question 9

what are the 3 chronic lower extremity wounds?

Answer 9

venous disease, arterial, neuropathic

Question 10

serous

Answer 10

thin watery wound drainage

Question 11

serosanguineous

Answer 11

watery drainage w/blood

Question 12

sanguineous

Answer 12

bloody wound drainage

Question 13

purulent

Answer 13

green/yellow wound drainage

Question 14

what does purulent indicate?

Answer 14

infection

Question 15

shearing (sitting) is associated with?

Answer 15

pressure injury

Question 16

pressure injuries can also be caused by?

Answer 16

medical devices (cath., oxygen tubing, wound drain)

Question 17

what is a risk of an occipital pressure injury?

Answer 17

tightly braided hair

Question 18

bed fast

Answer 18

like bed ridden

Question 19

shear force is?

Answer 19

2 layers of tissue are pulled in opposite directions

Question 20

pressure is?

Answer 20

continuous force exerted on or against object

Question 21

Malnutrition and low albumin levels leads to?

Answer 21

greater risk for developing pressure injuries

Question 22

hypoperfusion is?

Answer 22

low oxygen levels due to low circulation

Question 23

braden scale is?

Answer 23

rates pt risk for pressure ulcers

Question 24

stage 1 pressure injury

Answer 24

non-blanchable erthema

Question 25

stage 2 PI

Answer 25

parital thickness skin loss (pink tissue seen) in dermis

Question 26

stage 3

Answer 26

full thickness skin loss (granulation tissues: new skin tissue on wound)

Question 27

stage 4 full thickness skin/tissue loss

Answer 27

bone, muscle, tendons are seen, dead tissue is seen (pass sub q)

Question 28

once eschar is removed?

Answer 28

back to stage 4 or 3 PI

Question 29

for wound healing to occur, what type of dressing do u need?

Answer 29

moist

Question 30

example of open dressing?

Answer 30

gauze bandage

Question 31

semi open dressing have how many layers?

Answer 31

3

Question 32

when are films used?

Answer 32

covering superficial wounds with minimal exudate (fluid)

Question 33

flims allow?

Answer 33

mositure to evaporate while maintain a most wound bed

Question 34

when are hydrocolloid dressing used?

Answer 34

small abrasions, superficial burns, PI (maintain moist bed and growth of new tissue)

Question 35

what dressing does not stick to the wound bed?

Answer 35

polymeric membranes

Question 36

alginate dressings

Answer 36

for mod-high leaky wounds high absorption

Question 37

when are wound drains used?

Answer 37

reduce of accumulation of air, testin

Question 38

closed systems are more likely to

Answer 38

become contaminated with bacteria

Question 39

hematoma is?

Answer 39

Accumulation of blood in the body.

Question 40

seeroma is?

Answer 40

Accumulation of serous fluid.

Question 41

penrose drain uses?

Answer 41

gravity no collection chamber

Question 42

satured dressing means?

Answer 42

absorbed alot of fluid

Question 43

bottle drain is?

Answer 43

silicone drain with a bottle that is used when the amount of drainage is large

Question 44

portable wound bulb suction device

Answer 44

as a bulb drain, contains a flexible plastic bulb that connects to a plastic drainage tube

Question 45

skin adhesives are not?

Answer 45

used on joints

Question 46

what are the 3 stages of wound care?

Answer 46

hemostatic/inflammatory phase, proliferative, remodeling

Question 47

what happens in hemostatic phase?

Answer 47

1) blood vessels constrict, damaged tissue releases proteins to triggers blood clotting 2) histamine releases: vascodilation, increased cap. permeability

Question 48

when getting a culture from a wound you should not?

Answer 48

don't touch swab surrounding tissue

Question 48

remodeling phase is?

Answer 48

collagen replaced with stronger one, myofiberoblasts secrete protein (pulls open wound closed)

Question 48

what happens in prophetical phase?

Answer 48

dead skin is made, blood supply improves, collagen strenthens the wound

Question 49

why shouldn't we use wet to dry dressing not be used?

Answer 49

can cause tissue damage and linked to higher infection rates

Question 50

hydrocolloid dresses should not be used when?

Answer 50

presence of infection, tunneling or undermining

Question 51

Transparent dressings should not be used on?

Answer 51

wounds with exudate

Question 52

when is a wet gauze used?

Answer 52

wound packing when cont. debridement i needed

Question 52

where are langerhans cells found?

Answer 52

epidermis

Question 52

what do langerhans cells do?

Answer 52

ingest foreign antigens --> present lymphocytes--> trigger localized non-systemic immune response in epidermis

Question 53

what contributes to skin and hair color?

Answer 53

epidermal layer contains cells (ex. melanocytes)

Question 54

what dressing may develop a foul-smelling yellow film?

Answer 54

hydrocolloid (can cause dermaitis)

Question 55

who has a risk of getting tissue integrity?

Answer 55

pt with fractures

Question 56

second healing is?

Answer 56

wound is left open to heal and granulation tissues form, long time to heal

Question 57

when are foam dressing used?

Answer 57

mild-mod. drainage

Question 58

maceration

Answer 58

softening and breakdown of the skin due to TOO much moisture

Question 59

what is granulation tissue?

Answer 59

new tissue that forms on surface of wound (sign of healing)

Question 60

primary intention?

Answer 60

little/no tissue loss, surgical incision, low infection, (ex: staples, sutures, glue)

Question 61

what is an example of secondary healing?

Answer 61

pressure injury (left open)

Question 62

tertiary intention example?

Answer 62

abdominal wound (is deep)

Question 63

why do we use hydrocolloid dressing?

Answer 63

to keep granulating bed moist (prevents evaporation)

Question 64

what system speeds up tissue generation?

Answer 64

vacuum-assited closure system