Module 2: Wounds

Question 1

3 types of wound healing

Answer 1

primary, secondary, tertiary intention

Question 2

primary intention

Answer 2

surgical wounds closed with sutures/staples

Question 3

secondary intention

Answer 3

wound left open and heals through scar formation

Question 4

tertiary intention

Answer 4

delayed primary closure, left open for time and later closed

Question 5

stages of wound healing

Answer 5

hemostasis, inflammation, proliferation, remodelling

Question 6

factors that affect wound healing

Answer 6

age, edema, wrong dressing used for needs of the wound, nutritional deficit, impaired oxygen, accumulation of drainage, medications, immunosuppression, stressors, infections

Question 7

documentation of wounds

Answer 7

pain, size, bed, exudate (type, amount), odour, peri-wound care

Question 8

describing wound location

Answer 8

anterior & posterior, lateral & medical, proximal & distal

Question 9

measurement of a wound

Answer 9

length (longest measurement), width (widest measurement), depth (deepest part)

Question 10

describing a wound bed

Answer 10

r/t type of tissue present and expressed as an estimate % for each type of tissue observed

Question 11

types of tissues

Answer 11

granulation, eschar, slough, underlying structures (bone, tendon)

Question 12

granulation

Answer 12

healthy tissue, firm, red, moist, pebbled

Question 13

eschar

Answer 13

dry, black, brown, dead tissue

Question 14

slough

Answer 14

dry or wet, loose or firmly attached, yellow/brown - dead tissue

Question 15

types of wound exudate

Answer 15

serous, sanguineous, serosanguineous, purulent

Question 16

serous fluid

Answer 16

clear, thin, watery

Question 17

sanguineous

Answer 17

bloody drainage

Question 18

serosanguineous

Answer 18

clear with some blood

Question 19

purulent

Answer 19

thick, yellow, green, tan, or brown

Question 20

amount of wound exudate

Answer 20

non, scant, small, moderate, copious

Question 21

wound edge

Answer 21

attached or detached

Question 22

attached wound edge

Answer 22

flush with wound bed

Question 23

detached wound edge

Answer 23

not flush with wound bed - “cliff” sits above wound bed

Question 24

peri-wound skin

Answer 24

skin around wound

Question 25

types of peri-wound skin

Answer 25

erythema, maceration, induration, rash

Question 26

maceration

Answer 26

looks white - too much moisture

Question 27

induration

Answer 27

skin feels firm

Question 28

pressure injuries

Answer 28

located over bony prominences where prolonged pressure occurs

Question 29

stage 1 pressure injuries

Answer 29

non-blanchable erythema of intact skin

Question 30

stage 2 pressure injury

Answer 30

partial-thickness skin loss, exposed dermis

Question 31

stage 3 pressure injury

Answer 31

full-thickness skin loss

Question 32

stage 4 pressure injury

Answer 32

full-thickness skin and tissue loss

Question 33

unstageable pressure injury

Answer 33

obscured full-thickness skin and tissue loss

Question 34

deep tissue pressure injury

Answer 34

intact skin, dark red/purple bruise, firm to touch

Question 35

risk factors for impaired skin integrity

Answer 35

immobility, impaired sensory perception or cognition, decreased tissue perfusion, altered nutritional status, friction and shear, increase moisture

Question 36

arterial ulcers

Answer 36

r/t tissue ischemia, risk of infection

Question 37

location of arterial ulcers

Answer 37

lower legs, toes

Question 38

description of arterial ulcers

Answer 38

small, circular, deep & painful with minimal drainage

Question 39

venous ulcers

Answer 39

r/t impaired venous blood return

Question 40

location of venous ulces

Answer 40

lower leg, ankle

Question 41

description of venous ulcers

Answer 41

skin cool to touch, pale, shiny & may see hemosiderin straining and edema

Question 42

management of arterial and venous ulcers

Answer 42

antibiotics (if infection present), compression therapy (if not contradicted), debridement, wound dressings, hyperbaric oxygenation, negative pressure wound therapy, improving physical mobility, nutrition

Question 43

cause of diabetic ulcers

Answer 43

peripheral neuropathy, changes to foot structure seen in neuropathy, trauma/pressure

Question 44

location of diabetic ulcers

Answer 44

plantar foot structure

Question 45

management of diabetic ulcers

Answer 45

pt teaching, assess feet daily, how to clean feet (wash, dry, avoid moisture in between toes), wear closed-toe shoes that fit properly, how to trim toenails, reduce risk factors (smoking)