Wound Care : Info from Mosby's Canadian Textbook for the Support Worker - E-Book – Sheila A. Sorrentino, Leighann Remmert, Mary J. Wilk, Rosemary Newmaster

Question 1

A partial-thickness wound caused by the scraping away or rubbing of skin.

Answer 1

abrasion

Question 2

An open wound on the lower legs and feet caused by poor arterial blood flow.

Answer 2

arterial ulcer

Question 3

A wound that does not heal easily.

Answer 3

chronic wound

Question 4

An open wound on the lower legs and feet caused by decreased blood flow through arteries or veins.

Answer 4

circulatory ulcer

Also known as vascular ulcer .

Question 5

A wound that is not infected; microbes have not entered the wound.

Answer 5

clean wound

Question 6

A wound occurring from the surgical portal of entry into the urinary, reproductive, or digestive system.

Answer 6

clean-contaminated wound

Question 7

A wound in which tissues are injured but skin is not broken.

Answer 7

closed wound

Question 8

A wound with a high risk of infection; microbes have entered the wound.

Answer 8

contaminated wound

Question 9

A closed wound caused by a blow to the body.

Answer 9

contusion

Question 10

The separation of wound layers.

Answer 10

dehiscence

Question 11

Swelling in tissues caused by an accumulation of fluid.

Answer 11

edema

Question 12

Separation of the wound accompanied by protrusion of abdominal organs.

Answer 12

evisceration

Question 13

Resistance that skin encounters when it rubs against another surface such as clothing, bedding, or another fold of skin.

Answer 13

friction

Question 14

A wound in which the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved.

Answer 14

full-thickness wound

Question 15

A condition in which tissue dies and then decays.

Answer 15

gangrene

Question 16

The collection of blood under skin and tissues.

Answer 16

hematoma

Question 17

Localized tissue death as a result of disease or injury.

Answer 17

necrotic tissue

Question 18

A wound in which skin or the mucous membrane is broken.

Answer 18

open wound

Question 19

A wound in which the dermis and epidermis of skin are broken.

Answer 19

partial-thickness wound

Question 20

The excessive loss of blood within a short period.

Answer 20

hemorrhage

Question 21

An open wound with clean, straight edges; usually intentionally created with a sharp instrument.

Answer 21

incision

Question 22

A wound containing large amounts of bacteria and showing signs of infection. Also known as dirty wound .

Answer 22

infected wound

Question 23

A wound created for treatment.

Answer 23

intentional wound

Question 24

An open wound with torn tissue and jagged edges.

Answer 24

laceration

Question 25

An open wound in which skin and underlying tissues are pierced.

Answer 25

penetrating wound

Question 26

A type of soap that is used to wash skin. It is used primarily as a cleanser and deodorizer of the perineal area soiled by urine and feces. It also emulsifies (breaks up) feces to aid gentle, easy cleaning. Because it is pH balanced to the acid mantle (covering) of skin, it does not have to be rinsed off like other harsher soaps.

Answer 26

peri-wash

Question 27

A type of dressing in which the tape is applied to all four edges to reduce the likelihood of the dressing wrinkling or falling off.

Answer 27

picture-frame dressing

Question 28

A type of edema that is evident by (1) first compressing your fingers into the swollen tissues, (2) then removing your fingers, and (3) observing an impression of your fingers left in the skin.

Answer 28

pitting edema

Question 29

Any injury caused by unrelieved pressure.

Answer 29

pressure ulcer

Also known as decubitus ulcer , bedsore , or pressure sore .

Question 30

puncture wound

Answer 30

An open wound made by a sharp object; entry into skin and underlying tissues may be intentional or unintentional.

Question 31

Thick drainage from a wound or body orifice; this drainage is yellow, green, or brown and may indicate an infection.

Answer 31

purulent drainage

Question 32

Tearing of skin tissue caused when the skin sticks to a surface (usually the bed or chair) and deeper tissues move downward, exerting pressure on the skin.

Answer 32

shearing

Question 33

The condition that results when there is not enough blood supply to organs and tissues.

Answer 33

shock

Question 34

A break or rip in skin; the epidermis separates from the underlying tissue.

Answer 34

skin tear

Question 35

A type of adhesive bandage in which thin strips are applied across a skin tear; the dressing will bring the skin edges together and hold them together while the wound heals.

Answer 35

steri-strip

Question 36

A group of similar cells that perform a similar function together.

Answer 36

tissue

Question 37

An accident or violent act that injures skin, mucous membranes, bones, or internal organs or causes an emotionally painful, distressful, or shocking result, which often leads to lasting mental and physical effects

Answer 37

trauma

Question 38

Open wounds on the lower legs and feet caused by poor blood return through the veins.

Answer 38

venous ulcer

Also known as stasis ulcer .

Question 39

A break in the skin or mucous membrane.

Answer 39

wound

Question 40

What is the purpose of the skin?

Answer 40

protecting the body from infection and disease.
Heat regulation.
Excrete toxins.

Question 41

List the age-related changes in the skin

Answer 41

• Skin dryness
• Fragile and weak capillaries
• General thinning of the skin
• Loss of fatty layer under the skin
• Decreased sensation to touch, heat, and cold
• Decreased mobility • Sitting in a chair or lying in bed most or all of the day
• Persistent diseases (e.g., diabetes, high blood pressure)
• Diseases that decrease circulation
• Poor nutrition
• Poor hydration
• Incontinence
• Moisture in the dark areas of the body (skin folds, under breasts, between toes, and perineal areas)
• Pressure on bony parts
• Poor care of fingernails or toenails • Friction and shearing

Question 42

A wound that —has a high risk of infection; unintentional wounds (such as a stabbing) are wounds that are not created under sterile conditions, also occurs from breaks in surgical asepsis and from the spillage of intestinal contents.

Answer 42

contaminated wound

Question 43

A wound that —contains large amounts of bacteria and shows signs of infection; for example, old wounds, surgical incisions into infected areas (such as a ruptured appendix), and traumatic injuries that rupture the bowel

Answer 43

Infected wound (dirty wound)

Question 44

Skin tears occur due to

Answer 44

shearing, pulling, or direct pressure on skin.

Question 45

Skin tears are commonly caused by:

Answer 45

• Bumping a hand, arm, or leg on any hard surface such as a bed, bed rail, chair, wheelchair footrest, or table
• Holding on to a client’s arm or leg too tightly
• Repositioning, moving, or transferring a client without a transfer sheet or other non-friction surface, which can cause the client’s skin to rub against the surface and even tear
• Bathing, dressing, and other tasks
• Pulling buttons or zippers across fragile skin

Question 46

Clients at risk for skin tears include those who:

Answer 46

• Require moderate to complete help in moving
• Have poor nutrition or are very thin
• Are poorly hydrated • Have altered mental awareness; for example, clients with dementia may resist care and move quickly and without warning, which can cause skin tears
• Are older

Question 47

What can a PSW do to avoid causing client skin tears?

Answer 47

• Follow the care plan for moving, lifting, repositioning, transferring, dressing, and bathing the client. • Keep the skin moisturized. Follow the care plan.
• Offer fluids. Follow the care plan.
• Dress and undress the client carefully.
• Dress the client in soft clothing with long sleeves and long pants. Allow the client to make choices.
• Keep your fingernails short and filed smooth.
• Keep the client’s fingernails short and filed smooth. Report client’s long and rough toenails to your supervisor.
• Do not wear rings with large or raised stones or edges that could snag on anything.
• Follow safety guidelines when transferring or lifting the client to and from a bed or wheelchair
• Prevent friction and shearing during lifting, moving, transferring, and repositioning.
• Use a turning sheet to move and turn the client in bed.
• Use pillows to support arms and legs. Follow the care plan.
• Be patient and calm when the client is confused or agitated or resists care.
• Ensure that bed rails and wheelchair arms, footrests, and leg supports are padded. Follow the care plan.
• Provide good lighting to prevent the client from bumping into furniture, walls, and equipment.

Question 48

Pressure points that are moist with perspiration or body excretions are especially prone to developing a pressure ulcer, as well as bacterial infections that are very difficult to treat once they set in.
T or F

Answer 48

True

Question 49

The supine pressure points are:

Answer 49

back of head, shoulders, spine elbows, sacrum, heels

Question 50

In obese people, pressure ulcers can develop in areas where friction is caused by skin-to-skin contact.
T or F

Answer 50

True

Question 51

Some high risk areas for pressure ulcers are:

Answer 51

Skin over a bony prominence is squeezed between hard surfaces.
Skin to skin areas
Skin fold areas—under breasts, between abdominal folds, on legs and buttocks, and between toes

Question 52

Clients at risk for pressure ulcers are those who:

Answer 52

• Are confined to bed or a chair
• Require moderate to complete help in moving
• Have loss of bowel or bladder control
• Have poor nutrition • Have altered mental awareness
• Have problems sensing pain or pressure
• Have circulatory problems
• Are older • Are obese or very thin

Question 53

The first sign of a pressure ulcer is

Answer 53

pale skin or a warm, reddened area.

Question 54

Colour changes in skin may be hard to notice in dark-skinned clients, so if the client is complaining of pain, burning, itching, or tingling in the area, you should report this to your supervisor.
T or F

Answer 54

True

Question 55

Clients will always notice something unusual if they are developing a pressure sore.
T or f

Answer 55

False
Some clients may not feel anything unusual, so it is important that you observe your client and look for other signs of poor blood flow to the area.

Question 56

Which stage of pressure ulcers is this: The skin is gone, and the underlying tissues are exposed and damaged. There may be drainage from the area.

Answer 56

Stage 3

Question 57

Which stage of pressure ulcers is this: The skin is red. The colour does not return to normal when the skin is relieved of pressure

Answer 57

Stage 1

Question 58

Which stage of pressure ulcers is this: The skin cracks, blisters, or peels. There may be a shallow crater.

Answer 58

Stage 2

Question 59

Which stage of pressure ulcers is this: Muscle and bone are exposed and damaged. Drainage is likely.

Answer 59

Stage 4

Question 60

Good support care to prevent pressure ulcers includes:

Answer 60

Frequent position changes and ensuring a proper diet with lots of fluid, cleanliness, and skin care are essential.

Question 61

Repositioning for pressure ulcers should be at least

Answer 61

every two hours

Question 62

Massage massage pressure points to relieve stress.

T or f

Answer 62

False
Never rub or massage reddened areas, but massage the skin around the reddened area. Be careful to never scratch or irritate the skin.

Question 63

What can you do to keep the client’s heels off the bed?

Answer 63

Use pillows or other devices as directed. Place the pillows or devices under the lower legs from mid-calf to the ankles.

Question 64

What can you do to prevent skin on skin contact?

Answer 64

Use pillows and blankets to prevent skin-to-skin contact and to reduce moisture and friction.

Question 65

Remind clients sitting in chairs to shift their positions every 15 minutes to decrease pressure on bony points.
T or f

Answer 65

True

Question 66

To reduce the likelihood of shearing, do not raise the head of the bed to more than 45 degrees. Always follow your client’s care plan.
T or F

Answer 66

False

do not raise the head of the bed to more than 30 degrees

Question 67

Apply a moisturizer on dry areas—hands, elbows, legs, ankles, and heels, areas under the breasts, between skin folds, and between toes.
T or F

Answer 67

False
Apply a moisturizer on dry areas—hands, elbows, legs, ankles, and heels—but NOT on the areas under the breasts, between skin folds, and between toes.

Question 68

A metal frame placed on the bed and over the client.

Answer 68

A bed cradle (Anderson frame)

Question 69

Venous ulcers may “weep” fluid.

T or F

Answer 69

True

Question 70

Scratching is not a common cause of venous ulcers.

T or F

Answer 70

False

Scratching is also a common cause of venous ulcers.

Question 71

Some ulcers occur spontaneously, without any specific cause.

T or F

Answer 71

True

Question 72

To prevent venous ulcers :

Answer 72

• Apply elastic stockings or elastic wraps, according to the care plan and if you are allowed to do so.
• Remind the client not to sit with the legs crossed.
• Do not use elastic or rubber-band type garters to hold socks or hose in place.
• Provide good skin care daily. Clean and dry between the toes. • Avoid injury to client’s legs and feet. • Keep linens clean, dry, and wrinkle-free. • Follow the care plan for walking and exercise, as movement increases venous blood flow.
• Reposition the client at least every 2 hours. Follow the care plan.
• Elevate the client’s legs, according to the care plan.
• Have the client wear comfortable socks and shoes.
• Do not do anything that may irritate the skin. Avoid scrubbing or rubbing when bathing or drying the client.
• Avoid massaging over the pressure point. Never rub or massage reddened areas.
• Keep the heels off the bed. Use pillows or other devices, as instructed by your supervisor. Place the pillows or devices under the lower legs from mid-calf to the ankles.
• Use protective devices, as directed by your supervisor and the care plan.
• Report signs of skin breakdown, venous