Wound Managment

Question 1

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

Answer 1

Define puncture wounds

Question 2

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

Answer 2

Define primary intention

Question 3

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

Answer 3

Define Wound

Question 4

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

Answer 4

Define Granulation Tissue

Question 5

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

Answer 5

Define friction

Question 6

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

Answer 6

Define tissue ischemia

Question 7

impaired skin integrity related to unrelieved, prolonged pressure

Answer 7

Define pressure ulcer

Question 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.

Answer 8

Define sheer

Question 9

soft yellow or white tissue attached to wound bed.

Answer 9

Define slough

Question 10

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

Answer 10

Define abrasion

Question 11

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

Answer 11

Define laceration

Question 12

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

Answer 12

Define secondary intention

Question 13

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

Answer 13

Define approximation

Question 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.

Answer 14

Define eschar

Question 15

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

Answer 15

Define exudate

Question 16

hardening of a tissue

Answer 16

Define induration

Question 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

Answer 17

Define blanchable hyperemia

Question 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.

Answer 18

Define nonblanchable erythema

Question 19

Redness of a wound

Answer 19

Define hyperemia

Question 20

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

Answer 20

Define stage 1 pressure ulcer

Question 21

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

Answer 21

Define stage 2 pressure ulcer

Question 22

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

Answer 22

Define stage 3 pressure ulcer

Question 23

persistent nonblanchable deep red, maroon, or purple discoloration.

Answer 23

Define deep tissue pressure injury

Question 24

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

Answer 24

Define stage 4 pressure ulcer

Question 25

the removal of nonviable necrotic tissue

Answer 25

Define debridement

Question 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

Answer 26

Define mechanical debridement

Question 27

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

Answer 27

Define autolytic debridement

Question 28

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

Answer 28

Define chemical debridement

Question 29

use of scalpel or scissors to remove dead tissue

Answer 29

Define surgical debridement