Wounds!

Question 1

Assess open wound for:

Answer 1

Overall appearance, color, drainage, size, depth, undermining/tunneling, swelling, pain

Question 2

Assess closed surgical wound for:

Answer 2

Overall appearance, skin edges well approximated, closure, drainage, swelling, pain

Question 3

Factors influencing wound healing:

Answer 3

Age, diet, obesity, chronic diseases, smoking, tissue perfusion, medications, wound stress

Question 4

Stage 1 pressure injury:

Answer 4

red/purplish looking area, not blanchable, closed

Question 5

Stage 2 pressure injury:

Answer 5

partial thickness wound, looks like blister or top layer, skin barely open.

Question 6

Stage 3 pressure injury:

Answer 6

getting down into vascular layers of tissue, deeper, starts to look troublesome

Question 7

Stage 4 pressure injury:

Answer 7

as bad as it gets. Very gross. Muscle, tendon, ligament, bone are exposed

Question 8

Unstageable pressure injury:

Answer 8

wound where you can’t see the bottom of it. Top could be covered by dead tissue

Question 9

Deep tissue injury:

Answer 9

underneath skin, discoloration, purple/black

Question 10

Device related pressure injuries:

Answer 10

Pressure injuries resulting from a medical device creating localized tissue compression

Question 11

Interventions for device related pressure injuries

Answer 11

1. Secure devices with minimal pressure against underlying tissue
2. Use soft dressings or foam around rigid edges
3. If possible, remove/reposition devices daily and assess skin underneath

Question 12

Pressure Injury Prevention

Answer 12

Reposition: q2 in bed, q1 in chair; use pillows/wedges; use static air boots
Routine & PRN skin care: routine peri care, may require condom catheter or fecal management device, assess skin folds
Decrease friction & shear: lifting devices; head of bed less than 30
Nutrition: protein and hydration
Mobility: ambulate, the less they’re sitting/lying the better