Wound Buiznes

Question 1

Define Tunnels & Undermines

Answer 1

Tunnels- Cavities along fascial planes btwn layers under the skin
Undermines - cavities beneath the wound edges

Question 2

How do you calculate Percentage of healing per week?

Answer 2

[1 - (current SA / previous SA)] * 100

Ex. [1 - ( 32cm / 42 cm )] * 100 = 24 % healing

Question 3

What are the two ways to measure wound volume?

Answer 3

Jeltrate - alginate hydrocolloid that is poured into wound and provides a mold that can be measured threw water displacement
Saline - Saline is measured as injected into wound cavity

Question 4

Describe the color of granualtion, epithelialization, slough and escar

Answer 4

Granulation - pale red/beefy red
Epithelialization - white
Slough - yellow
Eschar - brown to black

Question 5

Skin temperature is indicative of what? What does increased & decrease skin temp mean?

Answer 5

Skin Temp monitors circulatory response of tx
Increased = inflammation/infection
Decreased = wound chronicity

Question 6

Define maceration

Answer 6

Softening of a tissue by soaking until the connective tissue fibers are so dissolved that the tissue components can be teased apart. Ex. wearing a bandaid in the shower
–wounds like this need to be protected from pressure and shear

Question 7

What are the systemic signs of wound infection?

Answer 7

Increased temp
Elevated WBC
Confusion/agitated
red streaks from wound

Question 8

What are the local signs of wound infection ?

Answer 8

Rubor
Calor
turgor
Dolor
exudate

Question 9

What is the widely known staging system for wounds called? & what does it do?

Answer 9

National Pressure Ulcer Advisory Panel (NPUAP) staging system
–Describes anatomic tissue loss

Question 10

Describe NPUAP Stage I characteristics

Answer 10

Intact, observable change, persistent redness, may have changes in temp/sensation,

Question 11

Describe NPUAP Stage II characteristics

Answer 11

Partial thickness involving epidermis and/or dermis, superficial abrasion, blister, no slough or eschar

Question 12

Describe NPUAP Stage III characteristics

Answer 12

Full thickness, damage or necrossis of subcutaneous tissue, may be down to but not through fascia, deep crater w or w/out undermining

Question 13

Describe NPUAP Stage IV characteristics

Answer 13

Full thickness, Extensive destruction and tissue necrosis, damage to muscle, bone, or supporting structures

Question 14

Describe NPUAP Unstable characteristics

Answer 14

covered with eschar and necrotic tissue

Question 15

Define Partial thickness wounds

Answer 15

Extend through epidermis and into, but not through dermis, 1-4 mm, heal by epithelialization

Question 16

Define Full Thickness wounds

Answer 16

Extend threw epidermis, dermis, and beyond, >4mm, heal by secondary intention