Wound Care

Question 1

phases of healing (3)

Answer 1

1. inflammatory phase2. proliferation phase3. maturation phase*all overlapping

Question 2

inflammatory phase

Answer 2

begins the moment of injury and lasts 2 days to 2 weeks initial vasoconstriction to control blood lossprotein-based fluid leaks out of vessels and swelling begins along with clean-up cellswithin 30 minutes mast cells release histamine to cause vasodialation

Question 3

proliferation phase

Answer 3

begins once injured area being clean and free of damaged tissue, foreign matter, and bacteria and last several weeksconsists of granulation, angiogenesis, wound contraction, and epithelialization*moist wound bed desired

Question 4

maturation phase

Answer 4

“remodeling phase”water and amino acids squeezed out of the granulation tissue matrixcollagen fibers produced, forms scar*can last up to 2 years

Question 5

scar vs skin strength

Answer 5

scar is 80% as strong as skin at full maturity*scar management is important

Question 6

factors that affect healing (9)

Answer 6

1. circulation2. debris in wound bed3. infection4. chemical stress5. temperature of wound bed6. amount of moisture in/around wound bed7. medications and other medical conditions8. nutrition9. age

Question 7

debridement

Answer 7

the removal of necrotic tissue from a wound so the healthy tissue is exposed in the wound bed

Question 8

slough

Answer 8

yellow, white stringy tissuemoist composite of fibrin bacteria, dead cells and exudate*dead tissue

Question 9

eschar

Answer 9

black, hard tissue, occasionally moist in appearance

Question 10

autolytic debridement

Answer 10

when the body breaks down the necrotic tissue on its owncan encourage with dressingscomfortable and effective, but slower*watch for macerated skin

Question 11

enzymatic debridement

Answer 11

use of topical enzymes to break down slough and escharcheck state practice actcollagenase ointment - needs Rx*may cause discomfort

Question 12

sharp debridement

Answer 12

use of sharp instrument (scissors/scalpel) to selectively remove necrotic tissuecheck state practice actneed to be skilled*fastest and most effective method

Question 13

mechanical debridement

Answer 13

remove of dead tissue using methods like whirlpool agitation, high pressure fluid irrigation, or wet-to-dry dressings**NOT RECOMMENDED

Question 14

hypergranulation tissue

Answer 14

looks like shiny, deep-red balls of tissue that grow taller than the wound marginsoft, bleeds easytreat with nitrate sticks (do with dressing changes/turns tissue gray)

Question 15

wound cleansing frequency

Answer 15

wound should be cleansed every time the dressing is changed

Question 16

best wound cleansing solutions

Answer 16

normal salinesterile waterdrinkable tap water

Question 17

wound cleansing solutions to avoid

Answer 17

hydrogen peroxide, Dakin’s solution, povidone iodine/Betadine, soap, bleach*never use anything you would not be willing to put in your eye

Question 18

hydrogen peroxide and wounds

Answer 18

should only be used in home setting to clean cuts/scrapes immediately after injuryonce wound is free from debris, OH can be toxic to granulation tissues and use can slow wound healing

Question 19

moisture balance

Answer 19

moist wound will heal much faster than a wound that is too wet or too dry

Question 20

goals of wound dressing

Answer 20

keep bacteria out, retain some moisture, but still absorb any excess fluid if needed

Question 21

non-occlusive dressing

Answer 21

allows for free passage of water, vapor, and bacteria

Question 22

occlusive dressing

Answer 22

will not allow passage of water, vapor, and bacteria

Question 23

semi-occlusive dressing

Answer 23

falls in the middleallows passage of water vapor, but not water or bacteria

Question 24

types of dressings (6)

Answer 24

1. transparent film2. impregnated low-adherence dressings3. hydrogels 4. gauze 5. foams 6. alginates

Question 25

transparent film dressings

Answer 25

semi-occlusivethin, see-through films that adhere right to the skin and can be used as primary or secondary dressing*can last up to 7 days

Question 26

impregnated low-adherence dressings

Answer 26

non-occlusive to semi-occlusivedesigned to make contact with wound and reduce sticking and tearing of wound tissue during dressing changes*requires secondary dressing*reduces risk of infection

Question 27

hydrogel dressings

Answer 27

non-occlusive to semi-occlusivedesigned to hydrate wounds and promote autolytic debridement*requires secondary dressing*needs to be changed every 24-72 hours

Question 28

gauze dressings

Answer 28

non-occlusivemost widely available and commonly usedcan be used to clean, pack, or cover wounds*as primary dressing it cannot easily create moist wound environment and also tends to shed fibers*good secondary to keep other dressings in place

Question 29

foam dressings

Answer 29

semi-occlusivemosty polyurethane and used to absorb moderate amounts of exudate and provide cushioning*can be primary or secondary depending on brand*doesn't conform well to hand

Question 30

alginate dressings

Answer 30

non-occlusive to semi-occlusivederived from seaweedhighly absorbent and made for moderate-large amounts of exudate*as alginate absorbs fluid, it is converted to a gel that provides moisture to the wound bed*requires secondary dressing

Question 31

primary intention

Answer 31

wound is closed with sutures or staples*wound heals by fibrous adhesion and little to no granulation tissue

Question 32

secondary intention

Answer 32

the wound is left open and left to heal through the granulation process*requires close monitoring

Question 33

tertiary intention

Answer 33

"delayed primary wound closure"wound is left open initially then closed a few days later

Question 34

patient education on wound care and smoking

Answer 34

*educate them that nicotine decreases the delivery of O2 to tissue and can increase the risk for wound healing complications* 1 cigarette can reduce blood flow to hand*encourage clients to temporarily stop smoking until wound is healed (or at least cut back)

Question 35

eval - location of wound

Answer 35

when describing the location of a wound, be precise do so in terms of anatomical positionex. "The wound is on the anterior medial aspect of the distal forearm, 2 cm proximal to the pisiform"

Question 36

eval - size of wound

Answer 36

length, width, depth recorded in mm or cmclock method or length and width at longest points

Question 37

eval - wound depth

Answer 37

depth measure by inserting a moistened sterile cotton-tipped applicator into the deepest part of the wound*look for tunneling

Question 38

tunneling

Answer 38

a narrow and deep hole that runs away from the main part of the wound*creates "dead space" and increases risk of abscess formation*record depth and location using clock face method

Question 39

eval - wound margins

Answer 39

note color and condition of edges of the wound*healthy: pink and flat, firmly attached to tissue underneath*watch for undermining

Question 40

undermining

Answer 40

space under the wound margins *sign that wound is not healing effectivley

Question 41

eval - periwound skin

Answer 41

note color and condition of skin around the wound*should be skin-colored or maybe a little pink*redness, inflammation or hardening could indicate infection*small lesions could indicate damage from adhesive dressings*soft, white indicates skin has absorbed too much fluid

Question 42

macerated skin

Answer 42

soft, white skin that results from wound exudate not being adequately absorbed by the wound dressing*fragile and easily damaged

Question 43

denuded skin

Answer 43

when the epidermis around the wound starts to breakdown

Question 44

eval - wound characteristics

Answer 44

describe wound using "red-yellow-black" system and document with digital photos to record wound healing progression

Question 45

"red-yellow-black" system

Answer 45

estimate what % of the wound is colored by each colorred: healthyyellow: sloughblack: eschar

Question 46

photographing wounds

Answer 46

helpful in documentingalways do at same point of treatment, same camera, same settings, same distance, NO FLASH

Question 47

eval - wound exudate

Answer 47

describe color, consistency, odor and amount of discharge*hydrocolloid dressings produce foul odor; this is normal so assess after cleaning

Question 48

serous

Answer 48

clear and watery exudate*normal

Question 49

serosanguinous

Answer 49

thin and pink exudate*normal

Question 50

sanguinous

Answer 50

thin and bright red exudate*may or may not be normal depending on amount and type of tissue in wound bed

Question 51

purulent

Answer 51

thick or thin, tan to yellow exudate*sign of possible infection

Question 52

foul purulent

Answer 52

thick, yellow to green exudate with bad odor*sign of infection

Question 53

signs of infection (9)

Answer 53

1. pain2. foul odor3. pus drainage4. redness5. warm to touch6. hardening around wound7. lymphangitic streaking/red streaks8. malaise9. fever

Question 54

wound care clinical reasoning (5)

Answer 54

1. moist wound healing is best2. create a clean wound bed3. wound bed is fragile4. infection must be identified5. do no harm