Wound Management and Assessment

Question 0

Name the four classifications wound types are apart of.

Answer 0

• acute
• chronic
• open
• closed

Question 1

Name four types of wounds.

Answer 1

• contused
• abrasion
• incised
• lacerated
• penetrating
• perforating
• burns
• fracture
• tumour

Question 2

Name three modes of healing.

Answer 2

• primary intention
• delayed primary intention
• secondary intention
• skin graft
• flap

Question 3

Explain primary intention.

Answer 3

There is minimal tissue loss and the wound edges are held together by sutures, clips, tape or glue. Scarring is minimal.

Question 4

Explain delayed primary intention.

Answer 4

When the wound is infected or contains foreign bodies and requires intensive cleaning prior to closure 3-5 days later.

Question 5

Explain secondary intention.

Answer 5

The wound heals by granulating up from the base, contracting in from the edges and epithelialisation across the wound bed. Here is always scarring.

Question 6

Name four general factors that affect healing.

Answer 6

• age
• sensory disorder
• vascularity
• nutrition
• obesity
• disease
• drugs
• radiation
• psychological state

Question 7

Name three local factors that affect healing.

Answer 7

• wound management
• wound hydration
• wound temperature
• pressure, friction, shearing forces
• foreign body
• wound infection

Question 8

Wound assessment is the key to delivering optimum wound management. This wound assessment needs to be:

Answer 8

• to be objective
• to include more than just observing the wound
• a knowledge base to work from
• to be a team approach

Question 9

Asides from vital signs, type of wound, size and location, what else would you need to take into consideration for your wound assessment? Name five.

Answer 9

• clinical appearance
• type of healing
• tissue loss/surrounding skin
• necrotic tissue
• exudate/drainage
• pain
• infection
• odour
• past treatment if any
• current treatment
• follow up/documentation

Question 10

Explain what we are assessing in wound location.

Answer 10

• anatomical positions and landmarks
• measurement dimensions
• is it two or three dimensional

Question 11

What are we assessing in wound measurement?

Answer 11

• width (is it 2cm? Or 5cm?)
• tracing (help determine the shape of the wound)
• depth (how deep the wound goes, and if it is tunnelling)

Question 12

When assessing exudate, what is included in our assessment?

Answer 12

• type
• amount
• colour
• consistency
• odour

Question 13

Name two types of exudate and explain each.

Answer 13

Purulent

• contains white cells and organisms, occurs when infection is present
• thick, opaque, pale yellow to green or tan

Sanguinous/blood
- from acute laceration

Haemoserous

• pale pinkish yellow
• contains plasma and red blood cells

Serous
- pale yellow, watery, like fluid from blister

Question 14

What are we looking for when assessing the surrounding skin of a wound?

Answer 14

• pain
• wound infection
• clean
• clean/contaminated
• infected

Question 15

What is the optimal wound environment?

Answer 15

• moist
• free from slough, debris
• protected from contamination
• temperature of 37 degrees
• normal pH level

Question 16

What is an aseptic technique?

Answer 16

A technique used to cleanse and dress a wound environment without allowing contamination to occur.

Question 17

What is contamination?

Answer 17

Wen microbes from outside the wound are introduced into a wound. It increases the potential for infection and occurs if the “wound field” comes into contact, directly or indirectly, with micro-organisms from a second environment.