Chapter 31 Wound Care

Question 1

biofilm is ___

Answer 1

a thick grouping of microorganisms

Question 2

epithelialization is ___

Answer 2

stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of “ground glass” to pink

Question 3

granulation tissue is ___

Answer 3

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

Question 4

maceration is ___

Answer 4

softening through liquid; overhydration

Question 5

subcutaneous tissue is ___

Answer 5

underlying layer that anchors the skin layers to the underlying tissues of the body

Question 6

j

Answer 6

Jaundice, a condition caused by excessive bile pigments in the skin, results in a yellowish skin color. The skin is often itchy and dry; patients with jaundice are more likely to scratch their skin and cause an open lesion, with the potential for infection.

Question 7

hiv risk

Answer 7

Assessment needs to include careful examination of the skin for purple blotches that may be indicative of Kaposi’s sarcoma.

Question 8

piercing assessment

Answer 8

Potential interference with airway management. Potential risk for bacterial and viral infections, scarring, nerve damage, tissue trauma, and deformity.

Question 9

GI procedure approach

Answer 9

The GI cleansing preparations administered to patients having GI studies done may result in diarrhea, which irritates the sensitive skin in the perianal area—especially if the patient had bouts of diarrhea before the studies; anticipating the problem, noting redness and inflammation, and beginning warm baths and ointments are welcome nursing measures that patients may be too embarrassed to seek.

Question 10

m

Answer 10

moist desquamation (loss of skin integrity).

Question 11

c

Answer 11

complex (the dermis and underlying subcutaneous fat tissue are damaged or destroyed).

Question 12

ecchymosis

Answer 12

a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.

Question 13

a

Answer 13

Avulsion Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Question 14

c

Answer 14

Avulsion Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Question 15

a surgical incision can cause a variety of systemic reactions, including increased body temperature, increased heart and respiratory rates, anorexia or nausea and vomiting, musculoskeletal tension, and hormonal changes.

Answer 15

n

Question 16

f

Answer 16

The blood transports increased numbers of leukocytes, erythrocytes, and platelets to the site of injury. Antibodies are carried by the plasma.

Question 17

j

Answer 17

Undernourished patients are at greater risk for developing a wound infection because they have difficulty mounting their cell-mediated defense system associated with T-lymphocyte activity, a

Question 18

l

Answer 18

Various vitamins, minerals, and trace elements are also needed for efficient wound healing. Vitamin A is necessary for collagen synthesis and epithelialization. Vitamin B complex serves as a cofactor of enzyme reactions needed for wound healing. Vitamin C is needed for collagen synthesis, capillary formation, and resistance to infection. Vitamin K is needed for the synthesis of prothrombin. Zinc, copper, and iron assist in collagen synthesis. Manganese serves as an enzyme activator.

Question 19

,

Answer 19

four phases will be discussed: hemostasis, inflammation, proliferation, and maturation.

Question 20

d

Answer 20

Hemostasis occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. The accumulation of exudate causes swelling and pain. Increased perfusion results in heat and redness. If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury. The platelets are also responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing.

Question 21

d

Answer 21

The inflammatory phase follows hemostasis and lasts about 4 to 6 days. White blood cells, predominantly leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing.

Question 22

x

Answer 22

The proliferation phase is also known as the fibroblastic, regenerative, or connective tissue phase. The proliferation phase lasts for several weeks.

Question 23

s

Answer 23

Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells.

Question 24

granulation tissue: new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

Answer 24

s

Question 25

x

Answer 25

The final stage of healing, maturation (or remodeling) begins about 3 weeks after the injury, possibly continuing for months or years. Collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger and more like adjacent tissue.

Question 26

d

Answer 26

Edema at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue.

Question 27

x

Answer 27

In addition, toxins produced by bacteria and released when bacteria die interfere with wound healing and cause cell death.

Question 28

Excessive bleeding results in large clots. Large clots increase the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue. In addition, accumulated blood is an excellent place for growth of bacteria and promotes infection

Answer 28

z

Question 29

elderly pt wound care labs

Answer 29

Monitor lab results such as serum albumin, total protein.

Question 30

c

Answer 30

fatty tissue is more difficult to suture, is more prone to infection, and takes longer to heal.

Question 31

z

Answer 31

Patients who are taking corticosteroid drugs or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Radiation depresses bone marrow function, resulting in decreased leukocytes and an increased risk of infection.

Question 32

aa

Answer 32

Chemotherapeutic agents impair or stop proliferation of all rapidly growing cells, including cells involved in wound healing. Prolonged antibiotic therapy increases a patient’s risk for secondary infection and superinfection.

Question 33

lupus

Answer 33

Suppression of the immune system as a result of disease (e.g., AIDS, lupus),

Question 34

x

Answer 34

Symptoms of wound infection usually become apparent within 2 to 7 days after the injury or surgery;

Question 35

wound infection complications

Answer 35

osteomyelitis (bone infection) and sepsis (presence of pathogenic organisms in the blood or tissues).

Question 36

c

Answer 36

An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence.

Question 37

c

Answer 37

he Semi-Fowler's position is the position of a patient who is lying in bed in a supine position with the head of the bed at approximately 30 to 45 degrees. Upright at 90 degrees is full or high Fowler's position. Semi-Fowler's would be tilted back to approximately 30 degrees.

Question 38

trochanter def

Answer 38

any of two bony protuberances by which muscles are attached to the upper part of the thigh bone.

Question 39

odd risk factor for pressure ulcar

Answer 39

History of corticosteroid therapy

Question 40

e

Answer 40

A stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence.

Question 41

d

Answer 41

A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer

Question 42

s

Answer 42

A stage III ulcer presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed.

Question 43

x

Answer 43

Stage IV ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle.

Question 44

d

Answer 44

Penrose Provides sinus tract After incision and drainage of abscess, in abdominal surgery T-tube For bile drainage After gallbladder surgery Jackson-Pratt Decreases dead space by collecting drainage After breast removal, abdominal surgery Hemovac Decreases dead space by collecting drainage After abdominal, orthopedic surgery Gauze, iodoform gauze, NuGauze Allow healing from base of wound Infected wounds, after removal of hemorrhoids

Question 45

maggots

Answer 45

Penrose Provides sinus tract After incision and drainage of abscess, in abdominal surgery T-tube For bile drainage After gallbladder surgery Jackson-Pratt Decreases dead space by collecting drainage After breast removal, abdominal surgery Hemovac Decreases dead space by collecting drainage After abdominal, orthopedic surgery Gauze, iodoform gauze, NuGauze Allow healing from base of wound Infected wounds, after removal of hemorrhoids

Question 46

Corticosteroids: how do they affect healing?

Answer 46

decrease the inflammatory process, which may delay healing.

Question 47

Describe gunshot wound care.

Answer 47

A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously