Wound classification and assessment and wound care management.

Question 1

wound classification

Answer 1

1- partial thickness where all or a portion of the dermis is intact;

2- full thickness where the entire dermis and sweat glands and hair follicles are severed, expose bone, tendon, or muscle

3- unstageable, a full-thickness loss where the true depth cannot be determined; deep tissue injury

Question 2

intentional wounds

Answer 2

such as surgery, intravenous therapy or lumbar puncture

wounds edges are clean and bleeding is usually controlled

Question 3

Unintentional wounds

Answer 3

accidental wounds.
such as
unexpected traumas, gunshots, burns, forcible injury.

wounds are jagged bleeding uncontrolled, high risk for infection.

Question 4

open wounds

Answer 4

Skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, increase in infection

Ex; incisions and abrasions

Question 5

Closed wounds

Answer 5

blow, force or strain caused by trauma. Skin is NOT broken, but tissue is damaged, internal injury and hemorrhage.
Ex; ecchymosis, hematomas.

Question 6

Acute wounds

Answer 6

Surgical incisions, usually heal within days to weeks.

edges are well approximated and risk of infection is low.

healing process is usually not interrupted

Question 7

Chronic wounds.

Answer 7

The wound edges are often not approximated, the risk of infection is increased,

healing time is delayed (>30 days).

remain in the inflammatory phase of healing

Question 8

Wounds healed by primary intention

Answer 8

well approximated (skin edges tightly together).

primary can become secondary if they become infected.

Question 9

Wounds healed by secondary intention

Answer 9

edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated,

Question 10

Wounds healed by tertiary intention

Answer 10

wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed

Question 11

Undernourished patients are at greater risk for developing a wound infection because

Answer 11

they have difficulty mounting their cell-mediated defense system associated with T-lymphocyte activity

Question 12

inflammatory phase

Answer 12

follows hemostasis and lasts about 2 to 3 days. White blood cells, predominantly leukocytes and macrophages, move to the wound.

macrophages enter wound.
ingest debris, release growth factors which release epithelial cells. Attracks fibroblasts that help fill the wound.

Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury.

Question 13

Hemostasis

Answer 13

Hemostasis occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering

causes swelling and pain

platelets simulate other cells to migrate to the injury

Question 14

proliferation phase

Answer 14

lasts for several weeks, fibroblastic, regenerative, or connective tissue.

new tissue is built to fill the wound space, primarily through the action of fibroblasts

granulation tissue, forms the foundation for scar tissue development

Collagen synthesis and accumulation continue, peaking in 5 to 7 days

Question 15

maturation (or remodeling) phase

Answer 15

3 weeks after the injury, and can continue for month or years.

scar, an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight, eventually becomes a flat, thin line.

Question 16

Desiccation

Answer 16

process of drying up. Cells dehydrate and die in a dry environment. This cell death causes a crust to form over the wound site and delays healing.

Question 17

Maceration

Answer 17

softening and breakdown of skin.
Exposure to moisture.
Overhydration of cells related to urinary and fecal incontinence can also lead to maceration and impaired skin integrity.

Question 18

Edema

Answer 18

interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue.

Question 19

Necrosis

Answer 19

Dead tissue present in the wound delays healing
Dead tissue appears as slough—moist, yellow, stringy tissue—and eschar appears as dry, black, leathery tissue

healing will not take place

Question 20

Biofilm

Answer 20

result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins.

Question 21

Circulation

Answer 21

adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria, and other debris is essential for wound healing

alder adults and in people with peripheral vascular disorders, cardiovascular disorders, hypertension, or diabetes mellitus may be imparied

Question 22

Oxygenation

Answer 22

tissues is decreased in people with anemia or chronic respiratory disorders and in those who smoke.

Question 23

wound healing requires what nutritional status

Answer 23

proteins, carbohydrates, fats, vitamins, and minerals

vitamins A - epithelialization

vitamins C - collagen synthesis.

Zinc plays a role in proliferation of cells.

Question 24

wound etiology

Answer 24

the cause of the wound

Question 25

hemorrhage

Answer 25

occur from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain.

Check the dressing and the wound under the dressing, if possible, frequently during the first 48 hours after the injury, and no less than every 8 hours thereafter.

Question 26

Dehiscence

Answer 26

is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

Question 27

evisceration

Answer 27

abdominal wound completely separates, with protrusion of viscera (internal organs) through the incisional area.

Question 28

fistula

Answer 28

abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another

Question 29

Pressure Injury

Answer 29

defined as localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a device

Question 30

common site for pressure injury

Answer 30

• occiput
• ear
• scapula
• elbow
• sacrum
• greater trochanter
• ischial tuberosities
• condyle of tibia
• fibular head
• medial malleolus
• lateral malleolus
• heel (calcaneus)

Question 31

Factors in Pressure Injury Development

Answer 31

external pressure that compresses blood vessels

friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin.

Question 32

external pressure

Answer 32

occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue to cushion damage to the skin.

results in occluded blood capillaries and poor circulation to tissues

Question 33

Insufficient circulation deprives tissue of oxygen and nutrients leads to

Answer 33

ischemia
hypoxia
edema

Question 34

friction

Answer 34

Occurs when two surfaces rub against each other.

Question 35

Shear

Answer 35

results when one layer of tissue slides over another layer.