Wound Care

Question 1

Acute wound

Answer 1

wound follows an orderly and timely healing process, such as surgical incision

Question 2

Chronic wound

Answer 2

wound does not heal easily and the skin does not soon return its normal appearance and function, such as pressure ulcer

Question 3

Primary intention

Answer 3

wound with little tissue loss

such as incision

Question 4

Secondary intention

Answer 4

wound involving tissue loss, becomes filled by scar tissue

such as burn, pressure injury

Question 5

Tertiary intention

Answer 5

delayed primary closure

wound left open and then closed after risk of infection is resolved

Question 6

Phases of partial thickness wound repair

Answer 6

Inflammatory response
Epithelial proliferation and migration
Re-establishment of epidermal layers

Question 7

Phases of full thickness wound repair

Answer 7

Inflammatory phase (reaction)
Proliferation phase (regeneration)
Remodelling (maturation)

Question 8

During healing, wound is replaced by

Answer 8

Granulation tissue

Question 9

Wound assessment includes..

6

Answer 9

1. Wound appearance
2. Character of wound drainage
3. presence of drains (jackson-pratt, hemovac, penrose)
4. wound closure
5. palpation of wound
6. pain

Question 10

What does presence of infection look like?

Answer 10

swelling, purulent, foul odor

sometimes, fever

Question 11

What should the nurse look for? nursing diagnosis

Answer 11

1. impaired skin integrity
2. impaired tissue integrity
3. impaired physical mobility
4. risk of impaired skin integrity
5. risk of infection
6. pain

Question 12

What are some interventions to promote wound healing?

Answer 12

1. wound dressing care
2. debridement
3. irrigating and packing wounds
4. other modalities (nutrition)
5. application of bandages

Question 13

Name some purposes of wound dressing

Answer 13

• protect from microorganisms
• aid in hemostasis
• absorb drainage
• support wound
• prevent patient from seeing the wound
• promote thermal insulation
• provide moist environment for wound bed

Question 14

What are the three layers of dressing?

Answer 14

Contact layer
Absorbent layer
Protective layer

Question 15

Principles for irrigating a wound

Answer 15

• done to remove debris or exudate
• fluid should flow out
• • least to most contaminated
• low pressure

Question 16

When swabbing wound for culture, where should one swab?

Answer 16

healthiest looking tissue, NOT pus or exudate

Question 17

Maceration

Answer 17

wound in contact with moisture for too long and becomes cold, wrinkly, soft and soggy to the touch

Question 18

What are some functions of bandages?

Answer 18

• create pressure
• immobilize body part
• support wound
• reduce edema
• secure dressing

Question 19

Hemorrhage

Answer 19

excessive bleeding

Question 20

Dehiscence

Answer 20

edges start to fall part, layers of skin and tissue separate

Question 21

Risk behaviours that made cause dehiscence

Answer 21

coughing, vomiting

Question 22

Evisceration

Answer 22

protrusion of visceral organs though wound opening, an emergent condition

Question 23

Fistulas

Answer 23

abnormal passage between two organs (i.e. fourth degree laceration during labour)

Question 24

Initiative to prevent Surgical Site Infections

Answer 24

1. perioperative antimicrobial coverage
2. appropriate hair removal
3. maintenance of perioperative glucose control
4. perioperative normothermia