Wound Care Key Points

Question 1

Sublethal injury

Answer 1

Alters function without causing cell death

Question 2

Lethal injury

Answer 2

An irreversible process that causes cell deaths

Question 3

What is common in cublethal injuries

Answer 3

Cell adaptations
-part of many normal physiological processes

Question 4

Hypertrophy

Answer 4

Increase in the size of cells
-resulting in increased tissue mass without cell division

Question 5

Hyperplasia

Answer 5

Increase in number of cells
-resulting from increased cellular division
-reversible when stimulus is removed

Question 6

Atrophy

Answer 6

Decrease in size of tissue or organ
-caused by decrease number of cells or reduction in the size of individual cells

Question 7

Metaplasia

Answer 7

Transformation of one cell type into another
-in response to a change in physiological condition or an external irritant

Question 8

Dysplasia

Answer 8

Abnormal differentiation of dividing cells that results in changes in their size, shape, appearance

Question 9

Anaplasia

Answer 9

Cell differentiation to a more immature or embryonic form

Question 10

Examples of individual cell death in normal situations

Answer 10

Skin, gut epithelium and embryogenesis

Question 11

Apoptosis

Answer 11

Programmed cell death
-human health dependant on this process

Question 12

When is cell death not a normal event

Answer 12

In developed tissues such as brain, liver, necrosis

Question 13

Inflammatory response

Answer 13

Sequential reaction to cell injury
-neutralizes and dilutes inflammatory agent
-removes necrotic materials
-creates healing environment

Question 14

The inflammatory response can be divided into

Answer 14

Vascular, cellular, formation and healing
-responses

Question 15

Vascular response

Answer 15

Results in vasodilation causing hyperaemia which raises filtration pressure
-increased blood flow in the area

Question 16

Cellular response

Answer 16

Neutrophils and monocytes move to the inner surface of the capillaries and then through capillary wall to site of injury

Question 17

Exudate

Answer 17

Consists of fluid, leukocytes that move from the circulation to the site of injury

Question 18

Nature and quantity of exudate depend on

Answer 18

Type and severity of the injury and tissues involved

Question 19

Healing includes two major components

Answer 19

Regeneration and repair

Question 20

Regeneration

Answer 20

Replacement of lost cells and tissues with cells of the same type

Question 21

Repair

Answer 21

More common type of healing, results in scar formation

Question 22

Primary intention

Answer 22

Healing takes place when wound margins are neatly approximated as in surgical incision or a paper cut

Question 23

Secondary intention

Answer 23

Healing occurs in wounds from trauma, ulceration and infection
-large amounts of exudate and wide irregular wound margins

Question 24

Tertiary intention

Answer 24

Healing occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together

Question 25

Three basic types of inflammation

Answer 25

Acute, subacute, chronic

Question 26

Acute inflammation

Answer 26

Healing occurs in 2 to 3 weeks and usually leaves no residual damage

Question 27

Subacute inflammation

Answer 27

Features of the acute process but lasts longer

Question 28

Chronic inflammation

Answer 28

Lasts for weeks, months, or even years

Question 29

Wounds can be classified by

Answer 29

-cause (surgical/non surgical or acute/chronic) -level of contamination -depth of tissue affected (superficial, partial thickness, full thickness) -color of wound (red, yellow, black)

Question 30

Complications of wound healing may include

Answer 30

Adhesions, contractures, dehiscence, evisceration, excess granulation tissue, fistula formation, infection, hemorrhage, formation of hypertrophic scars and keloids

Question 31

Best management of inflammation is prevention of

Answer 31

Infection, trauma, surgery, and contact with potentially harmful agents

Question 32

Three purposes of wound management

Answer 32

1. Cleaning a wound to remove any dirt and debris from wound bed 2. Treating infection to prepare the wound for healing 3. Protecting a clean wound from trauma so that it can heal normally

Question 33

Pressure injury

Answer 33

Localized injury to skin or underlying tissue -over bony prominence as result of pressure or pressure in combination with shear friction or both

Question 34

Shearing force

Answer 34

Pressure exerted on skin when it adheres to the bed and underlying skin layers slide in the direction of body movement

Question 35

What three things contribute to pressure injuries

Answer 35

-shearing force -friction -excessive moisture

Question 36

Care of a patient with pressure injuries revolves around the

Answer 36

Whole person -nutrition, pain management, control of other medical conditions, pressure relief

Question 37

Chances of wound infection are greater when

Answer 37

-wound contains dead or necrotic tissue -foreign bodies lie on or near wound -blood supply and tissue defences are reduced

Question 38

TIME framework

Answer 38

T- tissue management I- inflammation/infection M- moisture E- edge of wounds perimeter

Question 39

Dry gauze

Answer 39

Abrasions and non draining postoperative incisions -rapid moisture evaporation

Question 40

Pressure bandages

Answer 40

Control excessive, sudden, unanticipated bleeding -stops blood flow and promotes clotting

Question 41

Transparetns film dressings

Answer 41

Clear, adherent, nonabsorptive, impermeable to fluids and bacteria -prophylaxis on high risk intact skin, superficial wounds, with minimal exudate and Escher covered wounds

Question 42

Hydrocolloid dressings

Answer 42

Formed of elastomeric, adhesive, gelling agents -absorb drainage and hydrate and debride wounds

Question 43

Hydrogel dressings

Answer 43

Hydrate wounds -polyurethane foam dressings are capable of holding wound exudate away from wound bed -alienate dressings promote autolysis, granulation, epithelization

Question 44

Bandages are secondary dressings which provide

Answer 44

Protection, pressure, immobilization and anchorage of underlying dressings or splints

Question 45

Effective dressing control..

Answer 45

Wound moisture and drainage, protect the wound, debride dead tissue, and reduce the spread of infection

Question 46

Key components of a physiological wound environment are

Answer 46

Adequate moisture, pH balance, temperature control, low bacterial burden

Question 47

Dressing type used for autolytic debride ent of non infected wounds

Answer 47

Hydrocolloid dressing

Question 48

Dressing type that is useful to keep dressings intact and occlusive

Answer 48

Transparent film dressing

Question 49

Gauze dressing should be non woven if touching the wound bed (t/f)

Answer 49

True

Question 50

Used for moderate to heavy exudate wounds are adhesive or non adhesive and come in regular and lite versions

Answer 50

Foam dressing s

Question 51

The four phases of wound healing are hemostasis, inflammation, proliferation and maturation (t/f)

Answer 51

True

Question 52

Chronic wounds often stall in the inflammatory or proliferation phase of healing (t/f)

Answer 52

True

Question 53

Inflammation and infection are influenced by

Answer 53

Prescience of non viable tissue, high bacterial loads, and impaired leukocytes

Question 54

Tissue management involves removing non viable tissue from the wound (t/f)

Answer 54

True

Question 55

You have just removed a Hydrocolloid dressing from a venous ulcer, the exudate shows this wound is infected (t/f)

Answer 55

FALSE