Wk 4 Wound Management

Question 1

What is a potential cause of fragile skin?

Answer 1

A patient who has been on long-term systemic steroids

Question 2

What is an example of decreased circulation and oxygen as a cause of impaired wound healing?

Answer 2

peripheral vascular disease

Question 3

What are 9 factors that affect wound healing?

Answer 3

Age

Loss of skin turgor

Skin fragility

Decreased circulation and oxygenation

Slower tissue regeneration

Decreased absorption of nutrients

Decrease in collagen

Impaired immune function

Dehydration

Question 4

What 3 types of medications can affect wound healing?

Answer 4

Chemotherapy

Anti-inflammatories

Steroids

Question 5

What 2 labs can affect wound healing?

Answer 5

Decreased WBC

Low hemoglobin levels

Question 6

What 3 lifestyle factors can affect wound healing?

Answer 6

Obesity

Smoking

Malnutrition

Question 7

Wound impair skin __

Answer 7

Integrity

Question 8

What is inflammation?

Answer 8

A localized protective response to injury or destruction of tissue

Question 9

What are the 3 components of managing a patient’s wound?

Answer 9

Assessment

Cleansing

Protection

Question 10

What does red color typically mean on a wound?

Answer 10

Healthy regeneration of tissues

Question 11

What does yellow typically mean concerning wounds?

Answer 11

Purulent

Question 12

What does black typically mean for wounds?

Answer 12

Eschar

Question 13

What is eschar?

Answer 13

A dry, dark scab or falling away of dead skin, typically caused by a burn

Question 14

Eschar __ wound healing

Answer 14

impairs

Question 15

What should be noted when assessing a patient’s wound?

Answer 15

L x W x D

Sinus tracts

Tunnels

Redness/swelling around the wound

Drains

Pain

Question 16

Closed wounds that are healing by primary intention, skin edges should be…

Answer 16

Well approximated

Question 17

What are 3 ways skin edges are together by way of primary intention?

Answer 17

Staples

Sutures

Tissue adhesives

Question 18

What does approximated mean?

Answer 18

Edges are budding together (like a surgical incision)

Question 19

How do you measure tunneling?

Answer 19

Take q-tip and see if it goes into the wound (measure)

Question 20

What is undermining?

Answer 20

When there is a “lip” or a hangover of the wound

Question 21

What phases of healing does wound drainage accumulate?

Answer 21

Inflammatory and proliferative phases

Question 22

What should be documented about wound drainage? (5)

Answer 22

Amount

Odor

Consistency

Color

Integrity of surrounding skin

Question 23

If asked to measure drainage, how much is 1 ml of drainage?

Answer 23

1 gram

Question 24

What is copious amount?

Answer 24

Large area or volume

Question 25

Portion of serum that is watery and clear, or slightly yellow in appearance (like what is in blisters)

Answer 25

Serous exudate

Question 26

Serum + red blood cells, appears thick and red

Answer 26

Sanguineous exudate

Question 27

Exudate that contains serum and blood, watery, looks pale pink

Answer 27

Serosanguinous

Question 28

Describe purulent drainage

Answer 28

Result of infection thick contains WBC tissue debris and bacteria yellow, tan, green, brown

Question 29

Without adequate __ a wound will not heal

Answer 29

nutrition

Question 30

A patient with a wound will need what type of diet?

Answer 30

High protein, high carbohydrate High vitamin Moderate fat intake

Question 31

What two labs to monitor nutritional status?

Answer 31

Albumin Pre-albumin

Question 32

What is something you may want to do before changing a wound dressing?

Answer 32

Administer analgesics and monitor for pain management

Question 33

What does a wet-to-dry wound dressing do?

Answer 33

You put it on the wound wet, and when it is dry and you remove it, it mechanically debrides the wound

Question 34

Example of a self-adhesive, transparent dressing

Answer 34

Tegaderm

Question 35

What is a hydrocolloid dressing?

Answer 35

Occlusive dressing that swells in the presence of exudate

Question 36

What is an example of a hydrocolloid dressing?

Answer 36

Duoderm

Question 37

What is a hydrogel wound dressing?

Answer 37

Mostly water, gels after contact with exudate Promotes autolytic debridement, rehydrates and fills dead space

Question 38

What are hydrogel wound dressings used for?

Answer 38

Infected, deep wounds, or necrotic tissue

Question 39

What are hydrogel wound dressings not used for?

Answer 39

Wounds that drain a lot

Question 40

What are 2 advantages of hydrogel wound dressings?

Answer 40

Provides moist wound bed and can reduce pain Prevents skin breakdown in high-pressure areas

Question 41

What are alginate wound dressings?

Answer 41

Nonadherent dressing that conform to wounds shape and absorb exudate

Question 42

What are collagens?

Answer 42

Powders, pastes, granules, gels

Question 43

What is a wound vac?

Answer 43

Use of foam strips into the wound bed with occlusive dressing, creates negative pressure to occur once the tubing is connected

Question 44

What does a wound vac help with?

Answer 44

Tissue generation Decrease swelling Enhance healing in moist, protective environment

Question 45

What are two advantages of wound vacs?

Answer 45

Can infused antibiotics Counts output