Wounds

Question 1

Partial thickness

Answer 1

tissue destruction through epidermis

Question 2

Full thickness

Answer 2

tissue destruction through dermis to involve subq tissue and possibly bone/muscle

Question 3

Stage I

Answer 3

erythema of intact skin; no blanching; warmth, edema, induration or hardness may also be indicators

Question 4

Stage II

Answer 4

partial thickness to epidermis, dermis or both; superficial; clinically presents as an abrasion, blister or shallow crater

Question 5

Stage III

Answer 5

full thickness w/ damage or necrosis of subq, may extend to underlying fascia; presents as a deep crater w/ or w/o undermining

Question 6

Stage IV

Answer 6

full thickness w/ extensive necrosis or damage to muscle, bone or supporting structures; can have undermining or sinus tract

Question 7

Non-stageable

Answer 7

wound is covered w/ eschar and/or slough and cannot be accurately staged until deepest viable layer is visable

Question 8

Deep tissue injury

Answer 8

pressure-related deep tissue injury under intact

Question 9

How do you measure wounds?

Answer 9

L x W x Depth; Length = head to toe; W = hip to hip

Question 10

Tunneling

Answer 10

pathway that can extend in any direction from wound; results in dead space

Question 11

Undermining

Answer 11

tissue destruction underlying intact skin along wound margines

Question 12

Sinus tract

Answer 12

drainage pathway from deep focus of acute infection through tissue and/or bone to an opening on the surface

Question 13

Sanguineous exudate

Answer 13

thing, bright red

Question 14

Serosanguineous exudate

Answer 14

thin, watery, pale red to pink

Question 15

Serous exudate

Answer 15

thin, watery, clear

Question 16

Purulent exudate

Answer 16

thick or thin, opaque tan to yellow

Question 17

Foul purulent exudate

Answer 17

thick opaque yellow to green w/ offensive odor

Question 18

Scant amount

Answer 18

no measurable drainage

Question 19

Small amount

Answer 19

drainage <25% of dressing

Question 20

Moderate amount

Answer 20

drainage 25-75% of dressing

Question 21

Large amount

Answer 21

drainage >75% of dressing

Question 22

Nonadherent

Answer 22

easily separated from wound base

Question 23

Loosely adherent

Answer 23

pulls away from wound but attached to wound base

Question 24

Firmly adherent

Answer 24

does not pull away from wound

Question 25

Slough

Answer 25

lighter in color; thinner and stringy consistency; color can be yellow, gray, white, green, brown

Question 26

Eschar

Answer 26

darker in color; thicker and hard consistency; black or brown

Question 27

Granulation tissue

Answer 27

beefy red, granular, bubly in appearance; should be differentiated from smooth red wound bed; color of tissue red, pink, pale or full dusky red

Question 28

Indicators of infection

Answer 28

fever, streaking, redness, increased drainage, odor, warmth, elevated WBC, induration, malaise, edema, weeping, increased pain, discolorations

Question 29

Epithelialization

Answer 29

can appear as deep pink & progress to pearly pink/light purple from edges in full thickness wound or may form islands in the wound base w/ superficial wounds