Wound Care

Question 1

Reduction of blood flow to tissue

Answer 1

Tissue ischemia

Question 2

If tissue ischemia is relieved, vasodilation creates redness called

Answer 2

Hyperemia

Question 3

Why wouldn’t erythematous area blanch?

Answer 3

Deep tissue damage

Question 4

When normal red areas of light skinned patients are absent

Answer 4

Blanching

Question 5

What are 3 related factors of developing pressure ulcers?

Answer 5

1. Pressure intensity
2. Pressure duration
3. Tissue tolerance

Question 6

Extrinsic factors of tissue tolerance are:

Answer 6

Shear, friction, and moisture

Question 7

Systemic factors of tissue tolerance are:

Answer 7

Poor nutrition
Age
Low blood pressure

Question 8

Risk factors for pressure ulcers

Answer 8

1. Impaired sensory perception
2. Impaired mobility
3. Alteration in LOC
4. Shear
5. Friction
6. Moisture
7. Nutrition
8. Tissue perfusion
9. Infection
10. Pain
11. Age
12. Psychosocial impact of wounds

Question 9

Red, moist tissue composed of new blood vessels

Answer 9

Granulation tissue

Question 10

Stingy substance attached to wound bed

Answer 10

Slough

Question 11

Brown or black necrotic tissue

Answer 11

Eschar

Question 12

Amount, colour, consistency and odour of wound drainage

Answer 12

Exudate

Question 13

Response cause redness and swelling, and moderate exudate at wound edges.

Answer 13

Inflammatory response

Question 14

Epidermal cells at wound edged quickly resurface and migrate across wound bed

Answer 14

Proliferation and migration response

Question 15

New epithelium undergo reestablishment of epidural layers

Answer 15

Remodeling phase

Question 16

Clear, watery plasma

Answer 16

Serous

Question 17

Thick, yellow, green, tan or brown

Answer 17

Purulent

Question 18

Pale red watery mixture of clear and red fluid

Answer 18

Serosanguineous

Question 19

Bright red indicates active bleeding

Answer 19

Sanguineous

Question 20

What would the nurse assess from a wound?

Answer 20

1. Redness
2. Swelling
3. Drainage
4. Wound closure
5. Temperature
6. Pain
7. Wound cultures

Question 21

Partial or total separation of wound layers

Answer 21

Dehiscence

Question 22

Increased amount of serosanguinous drainage may indicate

Answer 22

Dehiscence

Question 23

Protrusion of visceral organs through wound opening

Answer 23

Evisceration

Question 24

Abnormal passage between two organs or organ and outside of body

Answer 24

Fistula

Question 25

Localized collection of blood underneath tissues

Answer 25

Hematoma

Question 26

Removal of non viable, necrotic tissue

Answer 26

Debridement

Question 27

Purple or maroon localized area of discoloured intact skin or blood-filled blister. Area is painful, form, mushy, boggy, warmer or cooler.

Answer 27

Deep tissue injury

Question 28

Intact skin with nonblanchable redness, usually over bony prominence.

Answer 28

Stage 1

Question 29

Partial thickness loss of dermis presenting as shallow ulcer with red pink wound bed, without sough. May also be intact or open or ruptured serum-filled blister.

Answer 29

Stage 2

Question 30

Full thickness tissue loss. Subcutaneous fat may be visible. Slough present but does not obscure tissue depth. May include undermining and tunnelling.

Answer 30

Stage 3

Question 31

Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present, often with undermining and tunnelling.

Answer 31

Stage 4

Question 32

Full thickness tissue loss, base of ulcer covered by slough or eschar.

Answer 32

Unstageable

Question 33

Wound that is closed

Answer 33

Primary intention

Question 34

Wound edges are not approximated

Answer 34

Secondary intention

Question 35

Wound closure is delayed until risk of infection is resolved, then wound edges are approximated

Answer 35

Tertiary intention

Question 36

Ulcer caused by inadequate blood flow

Answer 36

Arterial ulcers

Question 37

Superficial and irregularly shaped wound usually with large amount of exudate caused by edema

Answer 37

Venous Ulcers

Question 38

Superficial partial-thickness wound with little bleeding

Answer 38

Abrasion

Question 39

Jagged unintentional wound sometimes with more profuse bleeding

Answer 39

Laceration

Question 40

Small circular wound with edges coming together toward center

Answer 40

Puncture