Wound Care

Question 1

Blanchable erythema

Answer 1

Turns white when pressure placed over area then returns to red when pressure removed

Question 2

When does Erythema occur?

Answer 2

Occurs when there is ischemia to the tissue

Once pressure is relieved and blood flow returns the skin turns red

Question 3

Non blachable erythema

Answer 3

(BAD) When pressure placed over area it remains red

Question 4

What color is Eschar?

Answer 4

Black

Question 5

What color is Slough?

Answer 5

White

Question 6

What color is Exudate?

Answer 6

Pus, yellow, green thick; infected drainage.

Question 7

What color is Serous?

Answer 7

clear, yellow drainage

Question 8

What color is Serosanguineous?

Answer 8

Pink drainage

Question 9

What color is Sanguineous?

Answer 9

Bloody drainage

Question 10

What is Granulation?

Answer 10

New vascular tissue

Question 11

Pressure ulcer is defined as?

Answer 11

Definition: localized injury to the skin and underlying tissue

Question 12

Where do you usually find pressure ulcers?

Answer 12

Usually over a bony prominence
Significant health care problem
Adds to length of stay
Increases health care costs
Nurse sensitive indicator
Lack of reimbursement related to treatment

Question 13

Risk Factors for impaired skin integrity?

Answer 13

Decrease mobility
Decrease sensory perception
Moisture/Incontinence
Poor nutrition
Altered LOC (level of conciousness)
Shear and Friction
Age

Question 14

Pressure ulcer factors?

Answer 14

Pressure intensity (>32 mmHg), Pressure duration, Tissue Tolerance

Question 15

Stage 1

Answer 15

Non-blanchable redness of intact skin

Question 16

Stage 2

Answer 16

Partial thickness skin loss
Loss of dermis
Shallow open ulcer
Red/pink wound bed; no slough present

Question 17

Stage 3

Answer 17

Full thickness skin/tissue loss
Fat visible; Includes subcutaneous tissue
Some slough may be present

Question 18

Stage 4

Answer 18

Full thickness tissue loss
Muscle, bone, and/or tendon visible
Slough and/or eschar present
Often includes tunneling or undermining
Osteomyelitis can occur

Question 19

Unstageable

Answer 19

Base of wound can not be visualized secondary to slough or eschar

Question 20

Suspected deep tissue injury

Answer 20

Purple or maroon localized area of discoloration of intact skin

Question 21

Primary intention

Answer 21

Would that is closed, minimal scar. (Surgical incision; sutured would)

Question 22

Secondary intention

Answer 22

Would edges are not approximated. Heals by granulation tissue formation, wound contraction, an epithelization

Question 23

Tertiary intention

Answer 23

Wound left open for several days then edges approximated
Closure of wound delayed until risk of infection is resolved
Ex. Infected wounds

Question 24

Hemostasis

Answer 24

Controls blood loss and bacterial growth

Question 25

Inflammatory phase

Answer 25

Damage tissue secretes histamine, WBC, and exudate to damaged area

Question 26

Proliferative phase

Answer 26

Filling of the wound bed with granulation tissue, contraction of wound, and resurfacing with epithelization

Question 27

Remodeling phase

Answer 27

Final stage; collagen scar is formed

Question 28

Dehiscence

Answer 28

Layers of skin and tissue separate.

Question 29

Evisceration

Answer 29

Total seperation of would layers protrusion of organs.

Question 30

Interventions to prevent and treat wounds

Answer 30

``` Eliminate or reduce cause of pressure Nutritional support Increase mobility Reposition every 2 hours in bed Use pillows and wedges Reposition every 15 minutes in chair Keep HOB < 30 degrees Keep heels off loaded ex. waffle boots Manage moisture ex. barrier cream ```