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350 Midterm Wound care > Wound care > Flashcards

Wound care Flashcards

1
Q

What is the difference between acute and chronic wounds?

A

acute: wound proceeds through an orderly and timely reparative process, resulting into sustained restoration of anatomical and functional integrity
> causes: trauma, surgical incision
> implications of healing: wounds are easily cleaned, repaired and wound edges are clean and intact

Chronic: wound that does not proceed through an orderly and timely process, therefore not resulting into expected anatomical and functional integrity
> causes: vascular compromise, chronic inflammation, repetitive insults to the tissue
> implications of healing: continued exposure to insult impedes wound healing

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2
Q

which one of the following describes primary intention?

a) wound edges are not approximated
b) wound is closed
c) wound is left open for several days. then after few days its approximated

A

Answer: B

a) wound edges are not approximated - secondary intention
b) wound is closed - primary
c) wound is left open for several days. then after few days its approximated - tertiary/delayed primary

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3
Q

which one of the healing processes would a contaminated wound require?

a) primary intention
b) secondary intention
c) tertiary intention

A

tertiary intention healing process.

closure of wound is delayed until risk of infection resolved.
contaminated wounds require observation for signs of inflammation

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4
Q

which one of the healing processes would a surgical wound with tissue loss require?

a) primary intention
b) secondary intention
c) tertiary intention

A

secondary intention

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5
Q

Fill in the blanks:

in the secondary wound healing process, the wound heals by ___, ______ and ___.

A

in the secondary wound healing process, the wound heals by granulation of tissue formation, wound contraction and epithelialization.

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6
Q

which phase of the wound repair begins minutes after the injury and lasts for about 3 days?

a) epithelial proliferation and migration in full-thickness wound repair
b) re-establishment of epithelial layers in partial- thickness wound repair
c) inflammatory response phase in partial- thickness wound repair
d) inflammatory response phase in Full-thickness wound repair

A

in full thickness wound repair, the inflammatory phase begins minutes after injury until about 3 days.

in Partial thickness wound repair, the inflammatory phase starts within first 24 hours.

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7
Q

Which type of wound repair reflects secondary intention

a) full-thickness wound repair
b) primary-thickness wound repair
c) moderate-thickness wound repair
d) only tertiary intentions require wound repair

A

A) full thickness wound repair
because secondary intention is when the wound is not approximated and it requires granulation tissue formation, wound contraction and epithelialization

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8
Q

What are the phases for Full -thickness wound repair ?

A

1) inflammatory phase (reaction)
2) proliferative phase (regeneration)
3) Remodelling phase (Maturation)

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9
Q

What type of drainage indicates infection?

a) serous
b) serosanguinous
c) Purulent
d) Sanguineous

A

Purulent - pus , yellow, green

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10
Q

what type of drainage indicates active bleeding?

a) serous
b) serosanguinous
c) Purulent
d) Sanguineous

A

Sanguineous

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11
Q

Why are drains used?

A

Because we don’t want any accumulation any fluid in the wound bed which will inhibit the body’s ability to heal the wound because it will prevent the migration of cells that is supposed to replace it

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12
Q

Name 5 interventions to promote wound healing and explain.

A
  1. wound dressings - to protect from microorganisms. change them but not too often that disturbs the new cell growth
  2. debridement - removal of non-viable, necrotic tissue to provide a clean base for healing
  3. irrigating and packing the wound-
  4. culturing wounds - knowing the type of bacteria present in the wound or if it is present
  5. Nutrition - maintains immune competence and decreases the risk of infection
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13
Q

List 5 purposes of wound dressings.

A
  1. protect from microorganisms
  2. Aid in homeostasis
  3. promote healing by absorbing drainage and supports analytic debridement
  4. support/splint wound
  5. promote thermal insulation
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14
Q

How many layers does a traditional surgical dressing have? and what are they? State the purpose of each layer.

A

3 layers:

  1. Contact or primary layer- covers the incision
  2. absorbent layer- absorbs extra secretions
  3. outer protective layer - prevent from external contaminants
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15
Q

What type of dressing is the goal of many wounds?

a) dry
b) wet-to-dry
c) moist-to-dry
d) moist / wet

A

d) Moist /wet

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16
Q

True or False

a) cleanse wound with normal saline
b) cleanse from most contaminated to least
c) Use each gauze ONCE ONLY
d) irrigation solution should flow from most to least contaminated area
e) swab healthy looking tissue when taking a culture from a wound

A

a) cleanse wound with normal saline- T
b) cleanse from most contaminated to least - F (least to most contaminated area. starting from the wound bed and out)
c) Use each gauze ONCE ONLY - T
d) irrigation solution should flow from most to least contaminated area - F (from least to most)
e) swab healthy looking tissue when taking a culture from a wound - T

17
Q

What size of syringe is optimal for irrigation?

a) 10 mL
b) 3 mL
c) 1 mL
d) 35 mL

A

d) 35 mL as it will have the least pressure

18
Q

What are the principles of packing a wound

A

a) pack to eliminate dead space, otherwise fluid will accumulate
b) packing should be loose, while contacting all wound surfaces and not mounding above the skin surface
c) assess for undermining, tunneling
d) measure and record wound depth
e) protect integrity of skin around wound to prevent maceration

19
Q

State 5 reasons to why use bandages and binders?

A
  1. creating pressure
  2. immobilizing a body part (sprained ankle)
  3. supporting a wound (abdominal binder)
  4. reducing or preventing edema
  5. securing a splint
20
Q

what are the 5 complications of wound healing

A
  1. hemorrhage
  2. infection
  3. Dehiscence
  4. Evisceration
  5. Fistula
21
Q

How to assess the internal hemorrhage

A

a) swelling or distension
b) more drainage
c) bruising in independent areas
d) hypovolemic shock

22
Q

what are some signs of infection in the wound healing process?

A
  1. pain/tenderness
  2. edema
  3. inflammation of wound edges
  4. purulent discharge
  5. foul odour
23
Q

what are the 4 components of care to reduce SSIs

A
  1. perioperative antimicrobial coverage
  2. appropriate hair removal
  3. maintainence of perioperative glucose control, leading to better healing
  4. perioperative normothermia
24
Q

what are 3 risk factors for Dehiscence and state a nursing intervention

A
  1. poor nutrition
  2. failure of suturing
  3. obesity

Intervention: splinting the area with blanket or pillow

25
Q

List activities done by the nurse to prepare a client for a dressing change:

A
  1. administer required analgesics so that the peak effects occur during the dressing change
  2. describe the steps of the procedure to lessen client anxiety
  3. gather all supplies required
  4. answer questions about the procedure or the wound
  5. explain what you see
26
Q

explain how the nurse would assess wound edges

A

Palpation of wounds (wound edges): observe for swelling or separation of wound edges. Lightly press the wound edges to detect localized areas of tenderness or drainage collection. Note character of the fluid if it expresses.

27
Q

List and explain three principles to follow when cleansing a wound or the area around the drain.

A

a) Cleanse from the least contaminated (wound site) to the most contaminated (surrounding skin). Start in the wound bed and go out
b) Use one swipe motion and one gauze per swipe to prevent contamination
c) keep the area around the drain dry to prevent skin breakdown (in penrose drain)

28
Q

Describe Hyperemia

A

After a period of tissue ischemia (reduction of blood flow), if the pressure is relieved and blood flow returns, the skin turns red. The effect of this redness is vasodilation – called hyperemia (redness).

29
Q

Describe Blanching

A

Occurs when the normal red tones of light-skinned patients are absent. Does not occur in darkly pigmented skin

30
Q

Describe how hyperemia is evaluated.

A

Nurse must document the location, size and colour and reassess the area after 1 hour
 Abnormal reactive hyperemia = the nurse needs to outline the affected area with a marker to make reassessment easier
 Palpate the reddened tissue, observing for blanching as normal skin tones return in patients with light-toned skin
 Palpate for induration, noting size in mm or cm of the induration around the injured area
 Changes in the temperature of the surrounding skin and tissues should be also noted

31
Q

List and explain 2 factors that would put clients at risk for pressure injuries

A

Friction: the force of two surfaces moving across one another. Friction injuries affect the epidermis. Friction injury occurs in a patient who is dragged over the bed surface instead of being lifted.

Impaired mobility: risk of pressure injury development.

32
Q

state and describe 2 types of non-pressure injuries

A

1)arterial ulcer
• deeper and smaller than venous ulcers
• located on lower leg and feet
• wounds appear necrotic, black, crusted, and pale wound bed
• leg appears thin, shiny, taut
• resistant to healing
• caused by inadequate blood flow to the lower extremity

2) diabetic ulcer
• occur due to neuropathic changes
• found on bony prominences
• loss of protective sensation – decrease in the ability to feel pain and temperate change, absence of sweating leading to dry skin,

33
Q

Describe the stage 1 of pressure injury that is devised by national pressure ulcer advisory panel

A

Stage 1:

a) intact skin with non-blanchable erythema
b) presence of blanchable erythema or changes in sensation, temperature or firmness
c) may indicate deep tissue pressure injury
d) color changes are NOT maroon or purple

34
Q

risk factors of pressure injury

A

a) decreased sensory perception
b) moisture
c) friction and shear
d) decreased activity or mobility
e) poor nutrition

35
Q

Describe the stage 2 of pressure injury that is devised by national pressure ulcer advisory panel

A

a) partial thickness loss of skin
b) wound bed is pink or red and moist
c) granulation tissue, slough, and eschar are not present.

36
Q

Describe the stage 3 of pressure injury that is devised by national pressure ulcer advisory panel

A

a) full-thickness loss of skin
b) adipose tissue is visible
c) granulation tissue, slough, eschar may be visible
d) undermining and tunneling may occur

37
Q

Describe the stage 4 of pressure injury that is devised by national pressure ulcer advisory panel

A

a) full-thickness skin and tissue loss
b) direct palpation of fascia, muscle, tendon, ligament, cartilage or bone
c) slough and eschar are visible
d) undermining and tunneling

38
Q

Describe the unstageable “stage” of pressure injury that is devised by national pressure ulcer advisory panel

A

a) full thickness skin and tissue loss

b) extent of tissue damage within the ulcer cannot be confirmed b/c it is obscured by slough or eschar

39
Q

Describe skin tear, venous ulcer (non-pressure injuries) and malignant or fungating wound

A

Skin tear:
caused by shear friction and blunt force. resulting in risk of infection

Venous ulcer:
superficial and irregular in shape-caused by poor blood return. Venous insufficiency results in weak vein walls in the leg and therefore limited leg movements.

malignant or fungating wound:
cancer tumors may extrude through the skin as swollen masses with numerous diffuses that drain purulent, often very malodorous exudate, that sometimes bleed when cleaned or touched.
• typical sites- side of face or neck, the breast or groin area

350 Midterm Wound care (1 decks)

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