Wound Management (Borrowed from Prof. Courtney/NUR 330)

Question 1

Define puncture wounds

Answer 1

Usually a small, circular wound with the edges coming together toward the center. Main concern is infection and internal bleeding.

Question 2

Define primary intention

Answer 2

Skin edges are approximated, risk of infection low. Healing is quick with little scarring. Example: surgical incision.

Question 3

Define Wound

Answer 3

A disruption of the integrity and function of tissues in the body.

Question 4

Define Granulation Tissue

Answer 4

Red, moist tissue composed of new blood vessels. Indicates a progression toward healing.

Question 5

Define friction

Answer 5

The force of two surfaces moving across one another. Example: skin is dragged across bed linen

Question 6

Define tissue ischemia

Answer 6

The occlusion of capillaries for a prolonged period of time. The tissue is receiving insufficient oxygen and perfusion.

Question 7

Define pressure ulcer

Answer 7

impaired skin integrity related to unrelieved, prolonged pressure

Question 8

Define sheer

Answer 8

The sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary. Example: May occur when transferring a patient from bed to stretcher when the patient’s skin is pulled across the bed.

Question 9

Define slough

Answer 9

soft yellow or white tissue attached to wound bed.

Question 10

Define abrasion

Answer 10

A scraping or rubbing away of the epidermis resulting in a partial thickness wound that appears weepy with little bleeding

Question 11

Define laceration

Answer 11

An open, torn, jagged wound which may bleed profusely depending of depth and location.

Question 12

Define secondary intention

Answer 12

The wound involves loss of tissue and is left open until it becomes filled by scar tissue. Longer healing time.

Question 13

Define approximation

Answer 13

The wound edges are closed and the risk of infection is low.

Question 14

Define eschar

Answer 14

Thick layer of dead, dry tissue that covers a pressure injury or thermal burn. May be allowed to come off naturally or surgically removed. Black, brown, tan in color.

Question 15

Define exudate

Answer 15

Another name for drainage: fluid that is excreted by damaged cells. assess the color, amount, consistency and odor.

Question 16

Define induration

Answer 16

hardening of a tissue

Question 17

Define blanchable hyperemia

Answer 17

when a wound blanches (turns lighter in color) in response to light finger pressure and immediately turns red when pressure is removed. This is good. The wound is trying to overcome the ischemic episode

Question 18

Define nonblanchable erythema

Answer 18

a wound that does not blanch (turns lighter in color) in response to light finger pressure on the wound. This is not good. The wound may have deep tissue damage.

Question 19

Define hyperemia

Answer 19

Redness of a wound

Question 20

Define stage 1 pressure ulcer

Answer 20

nonblanchable erythema of intact skin. patient may report change in sensation, change in temperature over the area or firmness.

Question 21

Define stage 2 pressure ulcer

Answer 21

The wound bed is pink or red, moist. May present as a blister either intact or ruptured. Adipose tissue is not visible.

Question 22

Define stage 3 pressure ulcer

Answer 22

adipose tissue is visible. full thickness loss of skin. slough and or eschar may be visible.

Question 23

Define deep tissue pressure injury

Answer 23

persistent nonblanchable deep red, maroon, or purple discoloration.

Question 24

Define stage 4 pressure ulcer

Answer 24

exposed bone, muscle, tendon, ligament, or cartilage. Slough and or eschar may be visible. Epibole (rolled edges) tunneling and undermining often occur.

Question 25

Define debridement

Answer 25

the removal of nonviable necrotic tissue

Question 26

Define mechanical debridement

Answer 26

involves wet dressing being applied to a wound; when dry, the dressings are removed causing light debridement within the wound bed. Also, wound irrigation and whirlpool treatments

Question 27

Define autolytic debridement

Answer 27

lysis of necrotic tissue by the white blood cells and natural enzymes from the body

Question 28

Define chemical debridement

Answer 28

involves the use of a topical enzyme preparation such as Dakin’s solution or sterile maggots.

Question 29

Define surgical debridement

Answer 29

use of scalpel or scissors to remove dead tissue