wound care

Question 1

Stratum corneum

Answer 1

the outermost layer on skin

Question 2

stratum lucidum

Answer 2

the second layer

Question 3

Stratum granulosum

Answer 3

the third layer

Question 4

Stratum spinosum

Answer 4

the 4th layer

Question 5

Stratum germinativium

Answer 5

the inner most layer of the skin

Question 6

when does granulation tissue form

Answer 6

during wound healing

Question 7

what is granulation tissue

Answer 7

the new skin that grows during the healing process

Question 8

Partial thickness wound

Answer 8

limited to epidermis

Question 9

Full thickness wound

Answer 9

total loss of skin layer

Question 10

4 phases of wound healing

Answer 10

homeostasis, inflammatory, proliferative, maturation

Question 11

Homeostasis

Answer 11

-right after the injury
-clots form to seal off blood vessels
-platlets
-release growth factor and begin repair

Question 12

inflammatory

Answer 12

• Redness, swelling, warmth
  
  • Not infection
  • This is 1-4 days after
  • Neutrophils, macrophages, monocytes
  • Laborers clean up the sit (random with no specific job)

Question 13

proliferative

Answer 13

• Pebbled red tissue
  
  • 4-21 days after
  • Macrophages, pericytes, lymphocytes, angiocytes, neurocytes, fibroblasts, keratinocytes, epithelial
  • Now we have our very distinct labors (plumbers, framers) here to do their job
  • Fill defect, re-establish skin function, closure

Question 14

Maturation

Answer 14

• Remodelling stage
  
  • 21-years
  • Scar tissue
  • Deep pink
  • Fibrocytes and blasts, building tissue strength
  • Remodel or mature the skin
  • Tissue strength is only 80% of the old skin

Question 15

healing can be delayed by

Answer 15

infection
-poor tissue
-poor nutrition
-smoking
-obesity
-medication
-chemo
-immunosuppressants
-NSAIDs

Question 16

treatment goal for wound healing

Answer 16

maintain moisture balance (not too moist)
-Prevent infection
-protect surrounding skin
-reduce pain
-minimize odor

Question 17

Wound round

Answer 17

the edges of the wound

Question 18

analogy

Answer 18

the collagen is remodelled to become stronger. A scar may form. the tissue strength is only 80% of the old skin

Question 19

primary intention

Answer 19

• wound healing occurs when the edges of a clean surgical incision remain close together, tissue loss is minimal or absent

Question 20

secondary intention

Answer 20

wounds that are open and have tissue loss. Granulation tissue gradually fills in the area of the wound. Skin loss is present

Question 21

3rd intention

Answer 21

the wound is purposely left open for 3-5 days to allow edema or infection to decrease and then the wound edges are sutured or stapled shut

Question 22

venous ulcers

Answer 22

above ankle, medial lower leg

Question 23

Arterial ulcers

Answer 23

lower leg dorsum, foot, lateral border or foot, toe joint

Question 24

Neuropathic ulcers

Answer 24

plantar surface, lateral border of foot

Question 25

When doing a wound assessment note:

Answer 25

location, odor, size, undermining, tunnelling, wound base appearance, temp, peri wound

Question 26

Laceration wound

Answer 26

a cut, jacked edge

Question 27

Abrasion wound

Answer 27

scratch surface of skin

Question 28

contusion

Answer 28

bruise

Question 29

hematoma

Answer 29

collection of blood

Question 30

tunneling

Answer 30

A separation of the fascial planes leading to sinus tracts Usually involves a small % of the wound margins Usually narrow and long, and seems to have a destination

Question 31

Undermining

Answer 31

Usually involves a greater % of the wound margins, with more shallow length than tunnelling Usually involves subcutaneous tissues An erosion under the edge of the wound

Question 32

hyperkeratosis

Answer 32

when a wound edge is callus like

Question 33

maceration

Answer 33

softening of tissue by fluids

Question 34

exudate terminology

Answer 34

scant, moderate, large, copious

Question 35

Colours of exudate

Answer 35

serous, sanguineous, serosanguineous, purulent

Question 36

Serous

Answer 36

light yellow to clear

Question 37

sanguineous

Answer 37

bright and fresh

Question 38

Serosanguineous

Answer 38

light red or pink

Question 39

Purulent

Answer 39

thick, yellow, green, tan, brown

Question 40

granulation tissue

Answer 40

The growth of small blood vessels and connective tissue into the wound cavity

Question 41

what does healthy granulation tissue look like

Answer 41

bright, beefy red, shiny, and granular with a velvety appearance

Question 42

A pale granulation tissue indicates

Answer 42

ischemia, infection, or a co-morbidity such as anemia

Question 43

Hyper granulation tissue

Answer 43

A building up of tissue that prevents epidermal migration or resurfacing across the wound, by proliferating above the intact margins of the skin -excessive moisture

Question 44

Necrotic tissue

Answer 44

physical barrier to granulation, can harbour bacteria

Question 45

slough

Answer 45

Indicates less severity Yellow to tan mucinous or stringy material Loosely adherent to wound bed If non-adherent will be scattered through out wound

Question 46

Eschar

Answer 46

Indicates deeper tissue damage Black, gray, brown in color Usually adherent or firmly adherent May be soggy and soft or hard and leathery

Question 47

Smell of necrotic tissue

Answer 47

foul

Question 48

Smell of pseudomonas

Answer 48

sickening sweet with blue and green exudate

Question 49

wound irrigation PPE

Answer 49

-face shelf and mask and gloves

Question 50

stage 1 pressure ulcer

Answer 50

non blanching erythema with intact epidermis

Question 51

Stage 2 pressure ulcer

Answer 51

partial thickening ulcer involving epidermis and dermis

Question 52

stage 3 pressure ulcer

Answer 52

full thickness extending through dermis into subcutaneous tissue

Question 53

Stage 4 pressure ulcer

Answer 53

deep tissue destruction extending through fascia may involve muscle bone tendon

Question 54

unstageable pressure ulcer

Answer 54

depth of injury unknown to presence of necrotic tissue and eschar

Question 55

Pressure ulcer prevention

Answer 55

Encourage or assist with position changes, at least every 1–2 hours. Avoid prolonged moisture; protect skin from urine, stool or wound drainage if present. Utilize specialized mattresses, pads or cushions to relieve and redistribute pressure. Maintain tissue integrity with a well balanced, protein-rich diet.

Question 56

what is the sterile border

Answer 56

1 inch

Question 57

when cleaning a wound what should be cleaned first

Answer 57

inside then outside

Question 58

what happens if drainage accumulates in the wound bed

Answer 58

wound healing is delayed

Question 59

Open drain

Answer 59

drain fluid on to a gauze pad or into a stoma bag (ex Penrose)

Question 60

Closed drains

Answer 60

The collection device is connected to a clear plastic drain with multiple perforations. Drainage collects within a closed reservoir or a suction bladder. Drainage collects in a closed reservoir or a suction bladder

Question 61

When to change closed drain

Answer 61

when bag is half full

Question 62

How much can a JP drain hold

Answer 62

100 to 200 mL/24 hr;

Question 63

How much can a Hemovac drain hold

Answer 63

500mL/24hr (Accordion looking)

Question 64

serous

Answer 64

clear, watery. normal of healing

Question 65

serosang

Answer 65

pale, pink, water, mix of clear and red

Question 66

sang

Answer 66

Bright red, recent or active

Question 67

Purlent

Answer 67

Thick, yellow, green, foul odour infection

Question 68

Documenting drainage

Answer 68

Document emptying or re-establishing of vacuum in suction device; amount, colour, and odour of drainage; dressing change to drain site; and appearance of drain insertion site. Document amount of drainage on intake and output (I&O) record. Document to the health care provider a sudden change in amount of drainage, either output or absence of drainage flow. Also report to the health care provider pungent odour of drainage or new evidence of purulence, severe pain, or dislodgment of the drainage tube.