Wound deck II

Question 1

Granulation tissue

Answer 1

New connective tissue and tiny vessels that form on the surface of wounds during the early healing process

Question 2

Epithelialization

Answer 2

Epithelium is a membranous tissue made up of one or more layers of cells that contains very little intercellular substance. The process of epithelialization is the closing or sealing of a wound.

Question 3

Necrosis

Answer 3

Death of tissue usually from lack of blood supply

Question 4

Eschar

Answer 4

A dry tough scab or slough. Often seen with burns or cauterization of the skin.

Question 5

Exudate

Answer 5

A fluid that has moved out of tissue or its capillaries due to injury or inflammation

Question 6

Dehiscence

Answer 6

A surgical complication where the edges of a wound no longer meet. It is also known as wound separation. There may be drainage noted.

Question 7

Serous drainage

Answer 7

Clear, thin, watery plasma. Its normal during the inflammatory stage of wound healing

Question 8

Sanguineous exudate

Answer 8

Fresh bleeding, seen in deep partial thickness and full thickness wounds. A small amount may be normal during the inflammatory stage.

Question 9

Serosanguineous exudate

Answer 9

Thin, watery, and pale red to pink in color. The pink tinge, which comes from red blood cells, indicates damage to the capillaries with dressing changes.

Question 10

Seropurulent exudate

Answer 10

Thin, watery cloudy, and yellow to tan in color

Question 11

Purulent exudate

Answer 11

Thick and opaque. It can be tan, yellow, green, or brown in color. its never normal in a wound bed. BAD

Question 12

phagocytosis

Answer 12

the process of white blood cells that ingest smaller cells or cell fragments

Question 13

Slough:

Answer 13

the layer of dead tissue that separates tissue from sound flesh

Question 14

Angiogenesis

Answer 14

The growth of blood vessels to increase or return circulation to a healing tissue (1mm a day)

Question 15

Red wound

Answer 15

uninfected, granulation tissue, revascularization

Question 16

Yellow wound

Answer 16

Drainage, slough, delayed epithelization

Question 17

Black wound

Answer 17

Eschar, necrotic tissue

Question 18

Debridement

Answer 18

Manual removal of dead tissue, eschar, slough, and fibrin

Sharp debridement- scissors, scalpel
tweezers
chemical debridement
surgical debridement

Question 19

ways to classify wounds

Answer 19

open or closed

acute or chronic (new or old wound)

Partial thickness or full thickness

Question 20

acute wounds

Answer 20

abrasions (scrapes, road rash, laceration or incision- knofe, glaze, razor,
Avulsion- body structure is pulled or detached
Animal bites
Traumatic injuries- MVAs

closed wounds-
contusions, crush injuries, sprains

Question 21

chronic wounds

Answer 21

• wounds that fall outside the 3 phases of wound healing due to complications or severity
• Treatment is based on treating the underlying pathological condition
• Chronic wound can be converted to an acute wound with debridement
• Chronic wounds do not proceed through and orderly timely repair process.

Question 22

Primary dressing

Answer 22

the dressing that goes directly on top or inside of the wound

Question 23

Secondary dressing

Answer 23

Usually used to secure the primary dressing such as gauze, tegaderm, coban.

Question 24

Decubitus Ulcers

Answer 24

Also known as pressure ulcers, pressure sores, and bed sores

Question 25

NPUAP

Answer 25

main entity that puts out the regulations.

-tools the nurses use for wound assessment

Question 26

ulcers Stage 1

Answer 26

An area of localized redness that does not blanch when pressed. skin is intact.

• when push on the skin it does not turn white, stays the same color.

Question 27

Ulcers Stage 2

Answer 27

A shallow ulcer affecting only the epidermis. May be blistered or fluid filled. There is no slough present. Skin tears do not fall in this category.

-Only involved the epidermis, blisters

Question 28

Ulcers Stage 3

Answer 28

Deeper wound that extends into the subcutaneous tissue but does not go all the way through. May include tunneling and undermining

-Down to the subcutaneous tissue layer. The fatty stuff. Through all the dermis.

Question 29

Ulcers Stage 4

Answer 29

Full thickness tissue loss. The epidermis, dermis and subcutaneous tissue and may include muscle and bone. Tunneling and undermining common.

Question 30

Unstageable

Answer 30

The extend of the wound can not be measured or visualized. Usually blocked by eschar, necrosis, or blister. Deep tissue injury.

Question 31

Undermining

Answer 31

When the depth of the wound extends past the original opening. You can lift the lip of the wound off the wound border.

-The borders aren’t attached to the underlying tissue. Put q-tip underneath the wound.

Question 32

Tunneling

Answer 32

caused by destruction of the fascial planes which results in a narrow passageway. Tunneling results in dead space that has the potential for abscess formation.

Question 33

How to measure a wound

Answer 33

-important that the length is from head to feet direction and the width is from right to left.

Undermining- what time on a clock when the head of the wound is 12 oclock

Question 34

Medical treatment

Answer 34

wound Vacuum assisted closure

decreased bacterial level.

Question 35

Hyperbaric Oxygen therapy

Answer 35

Oxygen significantly increases the oxygen saturation of plasma available to the tissues.

Question 36

Prevention

Answer 36

turning schedules

• proper pressure reducing wheelchair cushions
• Hill-Rom or similar air bed
• Patient and family education, skin inspection
• Good nutrition
• monitor and control sugars if diabetic
• dressing changes if at home.

pressure sores can become septic