Wound Care Day 1

Question 1

Functions of Skin

Answer 1

thermoregulation, sensation, metabolism of Vit. D, protection from shear, protection from water loss

Question 2

aging effects on skin

Answer 2

decreases: thickness, fatty layer, collagen/elastin, sensation, metabolism, sweat glands, circulation, epidermal regeneration

Question 3

Epidermis

• regenerates in ____
• prevents ____
• synthesizes ___
• provides ____
• protection from ____

Answer 3

• 45-75 days
• water loss (90% keratinocytes)
• vit. D
• pigmentation
• shear, friction, toxic irritants

Question 4

Dermis

• houses ____
• ___ layer of skin
• provides _____ and ____

Answer 4

• sensory organs and vasculature
• thickest (2-4 cm
• structure (collagen) and elasticity (elastin)

Question 5

Hypodermis

• contains ___
• provides ____
• also called

Answer 5

• deep blood vessels and nerve endings
• insulation, energy reserve, cushion
• superficial fascia

Question 6

4 phases of wound healing

Answer 6

hemostasis, inflammatory, proliferation, remodeling

Question 7

components of hemostasis

Answer 7

immediate, vasoconstriction, platelet aggregation, fibrin deposition- clot is end product

Question 8

components of inflammatory phase

Answer 8

clean wound site for tissue restoration, vasodilation, phagocytosis

Question 9

signs of inflammatory phase

Answer 9

red, blue or purple skin, warm, pain, 3-7 days

Question 10

components of proliferation

Answer 10

skin integrity restored, 3-5 days to 3 weeks, angiogenesis, granulation, collagen synthesis, wound contraction

Question 11

components of remodeling phase

Answer 11

will not exceed 70-80% tensile strength of original (only 15% at closure), 21-28 days post injury up to 2 years,

Question 12

chronic remodeling

Answer 12

imbalance in collagen synthesis and lysis, dehiscence, keloids

Question 13

acute wounds

Answer 13

healing sequence continuous and within expected time frame, little complications, can get overreaction in healing (hypertrophic scars/keloids)

Question 14

chronic wounds

Answer 14

delay/failure of healing component, associated with repeated trauma, poor oxygenation, dormant, secescent cells

Question 15

when should a wound be assessed?

Answer 15

each time it is observed, and documentation should happen at least weekly

Question 16

How to measure wounds

Answer 16

length x width x height
in centimeters always
length- 12-6
width- 9-3

Question 17

depth

Answer 17

measure deepest area of wound bed, document clock time of undermining, tunneling, straight depth

Question 18

tunneling/sinus tract

Answer 18

tissue loss into the depths of the wound, dead space, measure pathway and document on clock time

Question 19

undermining

Answer 19

tissue loss parallel to wound surface

Question 20

Stages for all wounds except pressure ulcers

Answer 20

partial thickness- into but not through dermis

-full thickness- through dermis into subcutaneous tissue & muscle may be exposed

Question 21

Periwound inspection and palpation must be at least within ____

Answer 21

4cm of wound edge

Question 22

edema measurement

Answer 22

0-1/4 inch: 1+ mild
1/4-1/2 inch: 2+ moderate
1/2-1 inch: 3+ severe
>1 inch: 4+ very severe

Question 23

arterial occlusion

Answer 23

if capillary refill is longer than 2-3 seconds

Question 24

pulse grading

Answer 24

0= absent
1+= barely palpable
2+= palpable, but diminished
3+= normal
4+=prominent, suggestive of aneurysm

Question 25

ABI

Answer 25

ankle systolic/ brachial systolic | measures quality of blood flow to area

Question 26

Transcutaneous Oxygen measurement

Answer 26

30 mmHg will heal/debridement safe

Question 27

ABI results >1 <.3

Answer 27

``` calcified vessels arterial disease mild disease claudication debridement contraindicated compression contraindicated tissue loss ```

Question 28

Tissue types that could be present in a wound bed

Answer 28

eschar, slough, fibrin, granulation tissue, epithelium

Question 29

exudate - what is it? - what to document

Answer 29

- drainage | - amount, color, character (serous, serosanguinous, purulent, dressing residue)

Question 30

types of wounds

Answer 30

burns, arterial insufficiency, diabetic/neuropathic, pressure ulcers

Question 31

Superficial burns

Answer 31

epidermal involvement, erythema, tenderness, pain | -sunburn, hot liquid

Question 32

superficial partial thickness burns

Answer 32

dermal involvement, large blisters, pain, edema, weeping | -hot liquid, flame injury, flash injury

Question 33

deep partial thickness burns

Answer 33

small amount of dermis remains, white or charred, blood flow compromised, less pain -flame, chemical, electrical

Question 34

full thickness burn

Answer 34

into or through subcutaneous tissue | -flame, chemical, electrical injury

Question 35

arterial wound

Answer 35

result of complete or partial arterial blockage limiting perfusion causing tissue necrosis/ulceration

Question 36

illnesses associated with arterial wounds

Answer 36

coronary disease, CHF, COPD, hypertension, DM, ESRD, hypercholesterolemia

Question 37

arterial wounds - locations - surrounding skin - pulses

Answer 37

between toes and tips of toes, dorsal aspect of foot and over phalangeal heads, lateral malleolus, tibia - thin dry skin, absence of hair, shiny, smooth, cool to touch - absent or diminished

Question 38

arterial wounds - characteristics - symptoms

Answer 38

- dry gangrene, punched out, smooth edges, erythematous halo, black/gray necrotic tissue - wound is painful, decreased pain and increased redness in dependent position, claudication

Question 39

Chronic venous insufficiency ulcers - pathology - associated symptoms

Answer 39

- caused by valvular incompetence, obstruction of deep venous system, or congenital absence or malformation of venous valves - dull ache or heaviness, c/o pain in dependent position, decreased pain with elevation

Question 40

venous ulcers - location - wound characteristics - surrounding skin - pulses

Answer 40

- superior to malleoli, usually medial - eschar/slough, wet, yellow, exudate, irregular and shallow wound edges - dry and scaly, varicose veins, hemosiderin staining - present

Question 41

diabetic ulcers - location - causes

Answer 41

- tips of toes, lateral foot, dorsum, metatarsal heads, heels, deformities - neuropathic (60-70%), PVD, if to bone 90% have osteomyelitis

Question 42

diabetic ulcers - symptoms - surrounding skin - effect on healing

Answer 42

- delayed - cracking, callous formation - decreased collagen deposition, delayed everything

Question 43

diabetic neuropathies

Answer 43

sensory- most common autonomic motor

Question 44

contributing factors to pressure ulcers

Answer 44

pressure, shear, friction, moisture

Question 45

pressure ulcer risk factors

Answer 45

age, nutrition, smoking, low BP, poor O2 perfusion

Question 46

Pressure ulcers stage 1

Answer 46

intact skin, non-blanchable redness

Question 47

pressure ulcer stage 2

Answer 47

partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. may present as an intact or serum filled blister

Question 48

pressure ulcer stage 3

Answer 48

Full thickness tissue loss, subcutaneous fat may be visible, but not bone, tendon or muscle. May include undermining/tunneling

Question 49

pressure ulcer stage 4

Answer 49

full thickness loss with exposed bone, tendon or muscle. often include undermining and tunneling

Question 50

pressure ulcer-unstageable

Answer 50

full thickness tissue loss when base is covered and you can't see depth

Question 51

deep tissue injury

Answer 51

purple or maroon area of discolored intact skin or blood filled blister from pressure and/or shear.

Question 52

``` bruises 0-2 days 2-5 5-7 7-10 10-14 2-4 weeks ```

Answer 52

- red - blue - green - yellow - brown - clear

Question 53

Skin tear categories

Answer 53

1- no tissue loss 2- partial tissue loss 3- complete tissue loss