Wound Care

Question 1

localized injury to skin and other underlying tissue, usually over a bony prominence as a result of pressure, shear, or friction

Answer 1

Pressure Injury

Question 2

Two types of pressure injuries

Answer 2

those with loss of tissue and those without

Question 3

Acute wounds without tissue loss. The skin edges “approximate” and are easily pulled closed with sutures, clips, or “Steri-strips” These wounds heal in an orderly and predictable fashion–all the tissue layers heal at once. These wounds heal quickly (usually within 14 days)

Answer 3

Primary Intention healing

Question 4

Examples of Primary Intention healing

Answer 4

incisions and lacerations

Question 5

Tissue is lost, and therefore wound edges can’t be pulled together–there is a “cavity left underneath and a high risk of infection. Thus, the wound has to be left open (not sutured). These types of wounds heal from the “bottom up” as the wound fills with granulation tissue. Healing takes a long time.

Answer 5

Secondary Intention healing

Question 6

Examples of Secondary Intention healing

Answer 6

burns and pressure injuries

Question 7

Also called delayed primary closure. A wound in which the edges could be pulled together and closed with sutures or staples but is purposely left open for 3-5 days due to excessive drainage, hemorrhage, or infection in the wound before it is closed.

Answer 7

Tertiary Intention healing

Question 8

clear and watery clear and watery

Answer 8

Serous

Question 9

a pale red or pink and watery type of drainage (has some red blood cells in it)

Answer 9

Serosanguinous

Question 10

drainage that is primarily composed of actual bright red blood-a “thick” type of drainage. If the amount of blood is large, it is termed “hemorrhage”. Occasionally a hematoma (collection of blood beneath the surface of the tissue producing swelling) can form in closed wounds

Answer 10

Sanguineous

Question 11

“pus”—liquefied necrotic tissue; often indicative of infection

Answer 11

Purulent

Question 12

if the pressure applied over a capillary exceeds the normal capillary pressure

Answer 12

Pressure intensity

Question 13

the vessel is occluded for a prolonged period of time; could be low pressure over a prolonged period or high-intensity pressure over a short perio

Answer 13

Pressure duration

Question 14

The ability of tissue to endure pressure: depends on integrity of tissue & supporting structures & ability of underlying skin structures to help redistribute pressure

Answer 14

Tissue tolerance

Question 15

an increased amount of drainage from the wound, a change in the wound drainage

Answer 15

erythema

Question 16

partial separation of wound layers at the surface of the wound. The layers of the skin and tissue separate – this commonly occurs before collagen formation which is 3 to 11 days after injury or surgery.

Answer 16

Dehiscence

Question 17

Most commonly seen with abdominal wounds / abdominal surgeries. Obese patients are especially at risk (constant strain on the wound, plus the fact that that fatty tissue heals poorly). Patients with poor nutritional status, underlying infection, history of chronic disease such as diabetes or peripheral vascular disease

Answer 17

Dehiscence

Question 18

total separation of all layers of a wound with protrusion of abdominal organs. Is a medical emergency which requires surgical repair.

Answer 18

Evisceration

Question 19

If Evisceration occurs, we should

Answer 19

cover the wound with sterile cloths or dressings soaked in sterile saline

Question 20

Abnormal passageway connecting one epithelial surface with another epithelial surface

Answer 20

Fistula

Question 21

flexible rubber tube that usually lie under the wound dressing and often a clip is placed to prevent the drain from slipping further into the open wound.

Answer 21

Penrose

Question 22

bulb device with its own suction when fully compressed used for drainage

Answer 22

Jackson-Pratt (JP)

Question 23

to ensure an irrigation pressure is within the correct range it is best to use a

Answer 23

35 mL syringe with 19-gauge

Question 24

means removal of dead tissue

Answer 24

Debridement

Question 25

is loose, stringy, hydrated tissue that is usually yellow

Answer 25

Slough

Question 26

is dehydrated, thick, leathery tissue that is usually black

Answer 26

Eschar

Question 27

Wet-to-dry, Pulsed low-pressure irrigation, Whirlpool treatments

Answer 27

Debridement

Question 28

covering the wound with a dressing that supports moisture at the would surface

Answer 28

Autolytic

Question 29

application of a topical enzyme preparation that either dissolve or digest dead tissue

Answer 29

Chemical Debridement

Question 30

using a scalpel or other sharp instrument to cut away dead tissue

Answer 30

Surgical Debridement

Question 31

is good for superficial wounds with little drainage. Not absorbent. Also used for autolytic debridement. Can serve as “secondary dressings” over the top of alginates and gauzes.

Answer 31

Self-adhesive, transparent film

Question 32

the oldest and most common. Most often used to cover surgical incisions, keep them clean, and absorb small amounts of drainage. For routine surgical incisions, the initial dressing should be kept in place for 24-48 hours.

Answer 32

Dry Gauze

Question 33

A form of mechanical debridement. As the saline soaked dressing dries, it “sticks to” the wound and pulls away dead tissue when it is removed

Answer 33

Wet-to-dry dressings

Question 34

these really don’t represent the appropriate standard of care anymore. These kinds of dressings are “non-selective”- this means that in addition to stripping out necrotic tissue some viable granulation tissue is inevitably removed.

Answer 34

Wet-to-Dry dressings

Question 35

If using gauze in a clean, granulating wound that isn’t being debrided, NEVER allow it to dry out

Answer 35

Wet-to-moist dressings

Question 36

are an occlusive-type dressing impermeable to water, water vapor, and oxygen. Their contact layer also forms a gel with the exudate from the wound and keeps it moist.

Answer 36

Hydrocolloids

Question 37

available as sheets, impregnated gauze, or gels. They keep dry wounds moist and soothe and cool the wound. Not absorbent Often used for thermal burns and painful wounds.

Answer 37

Hydrogels

Question 38

An increasingly popular wound care choice. They have a non-adherent, moderately absorbent inner layer, and often a narrow adhesive silicone border all the way around to “seal the dressing shut”.

Answer 38

Foams

Question 39

made of a highly absorbent material manufactured from seaweed. They can absorb up to 40 times their own weight in fluid. Good for wounds which drain copiously. Do not use on dry wounds!

Answer 39

Alginates

Question 40

Sutures and staples usually removed _________ (provider’s order needed).

Answer 40

at 7-14 days