Wound Care

Question 1

Epidermis

Answer 1

Superficial Layer (Skin)

Question 2

Dermis

Answer 2

Deep layer (Skin)

Question 3

Subcutaneous Layer

Answer 3

Not part of this skin. Connective & adipose tissue.

Question 4

Two Types Dead Tissue In A Wound

Answer 4

Slough & Eschar. Must be removed before healing can take place.

Question 5

Slough

Answer 5

Moist, loose, stringy dead cells, appears yellow in color

Question 6

Eschar

Answer 6

Thick, dry leather-like tissue, black in color.

Question 7

Primary Pressure Ulcer Risk Factors

Answer 7

Pressure, Shear Forces, Poor Nutrition, Lack of Sensation, Incontinence

Question 8

Stage 1

Answer 8

Area of redness, epidermis. Skin intact.

Question 9

Stage 2

Answer 9

Partial thickness skin loss effecting the epidermis, dermis, or both. Appears moist and pink. Abrasion, blister, or shallow crater.

Question 10

Stage 3

Answer 10

Full thickness skin loss involving damage to or necrosis of subcutaneous. Deep crater. Bigger than appears on surface (undermining). Exudate may be observed.

Question 11

Stage 4

Answer 11

Destruction of deep tissue such as fascia, joint tissue, and bone. Necrotic tissue is likely to be present. Muscle or bone. Exudate may be observed.

Question 12

Wound Assessment

Answer 12

Identity the wound stageMeasure the wound size(Length, width,depth, tunneling & undermining)Observe and describe the tissue at the wound edgesObserve and describe the characteristics of any exudate(viscosity, amount, color)

Question 13

Wound Assessment Factors

Answer 13

Observe and describe the characteristics of any necrotic tissue.Describe wound colorObserve and describe surrounding skinObserve and describe characteristics of wound healing.

Question 14

Debridement

Answer 14

The removal of necrotic tissue from the wound. Sharp - Scalpel, scissors PTA cannot in most states. Non - sharp dressings.

Question 15

Sharp Debridement

Answer 15

Most rapid method

Question 16

Mechanical Debridement

Answer 16

Pressure irrigation, the removal of dressing, hydrotherapy, e-stim, ultrasound.

Question 17

Enzymes

Answer 17

Autolysis, effective for small areas of necrosis or when unable to tolerate other methods

Question 18

Semi Permeable Film

Answer 18

Made from transparent polyurethane membranes with H2O adhesives. For Stages I & II.

Question 19

Lacerations

Answer 19

Go through all layers of the skin and into the fat or deeper tissues.

Question 20

Puncture Wounds

Answer 20

Caused by sharp pointed objects entering the skin.

Question 21

Human or Animal Bites

Answer 21

Can be puncture wounds, lacerations, or a combination of both.

Question 22

Chronic Wounds

Answer 22

Diabetic Sores, Pressure Sores, Vessel Disease Wounds, Surgery Wound Breakdown, Spinal Injury Wounds, Chemical Wounds.

Question 23

Partial thickness

Answer 23

Superficial Wound.The epidermis and upper portion of the dermis are involved. Wound doesn’t reach subcutaneous tissues. Grade I & II

Question 24

Full thickness

Answer 24

Deep wound. Epidermis and entire dermis and subcutaneous tissues are involved (fascia, joint tissue, bone). Grade III & IV

Question 25

Pressure Ulcer Management

Answer 25

Provide relief or reduction. Debridement of necrotic tissue. Wound and skin cleansing. Cleanse ulcer with sterile saline. Dressing changes.

Question 26

Basic Goals of Wound Care

Answer 26

Protect wound and surrounding area from trauma. Reduce strain on tissues. Protect tissues from stress and movement in the area of the wound. Reduce pathogenic microorganisms. Expedite the healing process. Reduce formation of scar tissue.

Question 27

Moist Wound Healing

Answer 27

Maintains moisture allows the body to move cells into the entire area of injury. Reduced scar tissue and chance of infection.

Question 28

Dressing

Answer 28

Protect the wound, assist the healing process, reduce infection & contamination, remove exudates & toxic waste.

Question 29

Angiogenesis

Answer 29

New blood vessels grow in low oxygen environment

Question 30

Pain relief

Answer 30

Nerves are soothed

Question 31

Re-Epithelialization

Answer 31

Coverage of new skin is enhanced

Question 32

Semi Permeable Film Examples

Answer 32

3M Tegaderm, Polymem, Bioclusive, OpSite

Question 33

Hydrocolloid

Answer 33

Made up of gelatin, pectin, and/or carbonoxymethylcellulose in a poly isobutylene adhesive base. Dressing of choice for Stage II & III.

Question 34

Hydrogel

Answer 34

Contains approximately 96% H2O or glycerin. Transparent, comfortable, moisture-retentive, & permeable to O2. Stage II & III.

Question 35

Wet to Wet Dressing

Answer 35

Use on Stage II partial thickness and Stages III & IV. Changed every 8 hrs to maintain moist wound base.

Question 36

Wet to Dry Dressing

Answer 36

Stages II and IV wounds for Debridement. Slough and necrotic tissue will adhere to dressing, to be removed.

Question 37

Calcium Alginates Dressing (CaAl)

Answer 37

Used to absorb heavy drainage but will require secondary dressing to cover the CaAl.