wound objectives - Sheet1

Question 1

What are the stages of wound healing in partial-thickness wounds?

Answer 1

Involves the epidermis and partial dermis. Stages: Inflammatory response, epithelial reproduction and proliferation, resurfacing.

Question 2

What are the stages of wound healing in full-thickness wounds?

Answer 2

Involves dermal/hypodermal layer. Stages: Hemostasis, inflammatory response, proliferation, remodeling, and scar tissue formation.

Question 3

What is wound healing by primary intention?

Answer 3

Wound edges are brought together (usually with sutures) for quick healing.

Question 4

What is wound healing by secondary intention?

Answer 4

Wound edges don’t meet and heal from the inside out, filling with tissue and forming a scar.

Question 5

What is wound healing by tertiary intention?

Answer 5

Wound is initially left open and closed later after cleaning to reduce infection risk, also called delayed primary intention.

Question 6

How does nutrition affect wound healing?

Answer 6

Nitrogen balance and increased protein support healing. Vitamins A & C aid collagen formation, and zinc is important for skin repair.

Question 7

How does body composition affect wound healing?

Answer 7

Obesity can slow healing due to poor circulation and other factors.

Question 8

How do underlying illnesses affect wound healing?

Answer 8

Chronic diseases (e.g., diabetes, heart disease) and malabsorption can slow healing by affecting nutrient absorption.

Question 9

How does oxygen delivery impact wound healing?

Answer 9

Conditions like iron deficiency or anything affecting oxygen flow can delay healing.

Question 10

How do altered inflammatory responses impact wound healing?

Answer 10

Immunosuppression (e.g., cancer, chemotherapy) weakens the immune response, delaying healing.

Question 11

How does vascular insufficiency affect wound healing?

Answer 11

Poor circulation (e.g., peripheral vascular disease) slows healing.

Question 12

How does infection impact wound healing?

Answer 12

Infection prolongs inflammation, delays collagen formation, and increases energy needs.

Question 13

How does aging affect wound healing?

Answer 13

Aging slows healing due to delayed inflammatory response, collagen formation, and epithelialization.

Question 14

How do psychosocial factors impact wound healing?

Answer 14

Body image issues (scars, drains, ostomies) and social habits (smoking, alcohol) can harm healing.

Question 15

What other factors impact wound healing?

Answer 15

Mobility issues and drug therapy (e.g., chemotherapy, radiation) can also slow healing.

Question 16

What is hemorrhage in wound healing?

Answer 16

Hemorrhage is visible external bleeding or internal bleeding (hematoma). Risk is highest in the first 24-28 hours after surgery.

Question 17

What is infection in wound healing and when does it occur?

Answer 17

Infection is the second most common hospital infection and occurs 2-3 days to 30 days after surgery. Risk is higher with dirty wounds or underlying health issues.

Question 18

What is dehiscence in wound healing and when does it occur?

Answer 18

Dehiscence is partial or total opening of the wound, occurring most commonly 3-11 days after surgery. Signs include increased drainage or a feeling of the wound opening.

Question 19

What is evisceration in wound healing and when is it a concern?

Answer 19

Evisceration is complete separation of the wound with organs protruding. It is a surgical emergency and requires immediate care, such as covering with moist gauze.

Question 20

What is fistula formation in wound healing?

Answer 20

A fistula is an abnormal passageway formed, often after blood or lymphatic vessels are damaged during surgery, leading to fluid collection. Drains may be placed to remove fluid.

Question 21

What defines a Stage I pressure ulcer?

Answer 21

Intact skin with redness that does not go away when pressed.

Question 22

What characterizes a Stage II pressure ulcer?

Answer 22

Partial-thickness loss of skin involving the outer or inner layers (epidermis or dermis). It may appear as an intact or broken blister.

Question 23

What defines a Stage III pressure ulcer?

Answer 23

Full-thickness loss of skin with visible fat exposed.

Question 24

What is a Stage IV pressure ulcer?

Answer 24

Full-thickness loss of skin exposing bone, muscle, or tendon.

Question 25

What does “unstageable” mean in pressure ulcer classification?

Answer 25

The wound bed is not visible and is covered by slough or eschar (dead tissue).

Question 26

What is a Deep Pressure Injury?

Answer 26

Intact or broken skin with deep red, purple, or maroon discoloration, potentially including a blood-filled blister or deep wound.

Question 27

What are the risks and contributing factors to pressure ulcer formation?

Answer 27

Risks: Pressure intensity, tissue ischemia, pressure duration, tissue tolerance. Contributing factors: Impaired sensory perception, impaired mobility, alteration in LOC, poor nutrition, shear, friction, moisture, incontinence, excessive sweating (diaphoresis).

Question 28

What is the pathogenesis of pressure ulcers?

Answer 28

Prolonged pressure impairs blood flow, cellular function, and causes tissue ischemia and death.

Question 29

What is the difference between acute and chronic wound care?

Answer 29

Acute care focuses on debridement, nutritional status, and hemoglobin levels. Chronic care involves specialist oversight, ongoing debridement, and long-term wound management, with emphasis on continued nutrition, protein, and blood levels.

Question 30

What are nursing diagnoses associated with impaired skin integrity?

Answer 30

Risk for infection, sepsis, imbalanced nutrition (less than body requirements), acute or chronic pain, impaired physical mobility, impaired skin integrity, ineffective peripheral tissue perfusion, impaired tissue integrity, social isolation, impaired body image.

Question 31

What are appropriate nursing interventions for a client with impaired skin integrity?

Answer 31

Interventions: Hemostasis (control bleeding), cleaning and protection, dressing application (gauze, hydrocolloid, foam), and wound assessment. Best practices include preparing the patient, evaluating pain, and following dressing change procedures.

Question 32

What are the purposes of wound dressings?

Answer 32

Protects from microorganisms, aids in hemostasis, promotes healing, absorbs drainage or debrides a wound, supports the wound site, provides thermal insulation, creates a moist environment, and protects from seeing the wound.

Question 33

What are the types of dressings used for wound care?

Answer 33

Gauze, transparent film, hydrocolloid, hydrogel, foam. Dressing closures include tape (paper, ties, binders).

Question 34

What are best practices for dressing changes?

Answer 34

Know the dressing type and equipment needed. Prepare the patient, review the previous wound assessment, evaluate pain, and administer analgesics. Explain the procedure to reduce anxiety. Recognize normal healing signs.

Question 35

What is involved in drainage evacuation?

Answer 35

Penrose, Jackson Pratt (JP), and Hemovac drains are used to remove drainage. Empty drains when 50% full or once per shift. Document COCA (color, odor, consistency, amount) and note any sudden changes.

Question 36

How should skin and drain sites be cleaned?

Answer 36

Clean from least contaminated to surrounding skin, using gentle friction. Wound irrigations should flow from least contaminated to most contaminated.

Question 37

What is involved in wound packing?

Answer 37

Negative-pressure wound therapy helps draw edges together, decreases edema, and supports granulation. Wet-to-dry dressings maintain moisture, wick out drainage, and help debride tissue.