Stages of Wound Healing and Pressure Ulcer Treatment, Exams of Nursing

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Wound Care stages of healing 2024

What are the four stages of wound healing?\ CORRECT ANSWER IS Homeostasis - vessels constrict, platelets aggregate, bleeding Inflammation - stimulation of capillary growth Proliferation - granulation tissue is formed Remodeling - strengthening the wound True or False: The phases of wound healing can be disrupted.\ CORRECT ANSWER IS True True or False: Red beefy tissue is helping the healing process.\ CORRECT ANSWER IS True, it's called red granulation tissue What are building blocks of wound healing\ CORRECT ANSWER IS fibroblasts, collagen and glycoproteins, epidermal cells True or False: The area where a wound as healed will only have 60% of the strength that it had before the would occurred\ CORRECT ANSWER IS False, it will be 80% What is important to consider when treating wounds?\ CORRECT ANSWER IS To support the phases of wound healing and to make sure not to disrupt them Black or yellow sloughing tissue indicates what?\ CORRECT ANSWER IS Dead tissue What is white tissue that is non-viable and it is caused by exposure to moisture?
CORRECT ANSWER IS Maceration True or False: The maturation phase of wound healing could last as long as one year or more.\ CORRECT ANSWER IS True True or False: It is unimportant to investigate the history of the wound and find the underlying cause.\ CORRECT ANSWER IS False, it is very important to get a complete health history and find the cause of the wound to treat it properly. What are some factors that would impair wound healing?\ CORRECT ANSWER IS Issues with tissue perfusion, oxygenation, diabetes, BP, anemia, low serum albumin, decreased food intake, malnourished and body weight What are the signs of an infection in a wound?\ CORRECT ANSWER IS Reddened peri-wound tissue, changes in V/S, high white count How do corticosteroids impair healing?\ CORRECT ANSWER IS They suppress the immune system and slow the process of would healing

When you first notice a Stage I pressure ulcer, what should you do?\ CORRECT ANSWER IS RELIEVE PRESSURE! Remove moisture, reduce friction and shear True or False: When a pressure ulcer is staged at diagnosis, it remains that same stage until it is healed.\ CORRECT ANSWER IS True What is a Stage I Ulcer?\ CORRECT ANSWER IS Non-blanchable erythema of intact skin, can be firm/boggy, or colder/warmer than surrounding skin What is a Stage II Ulcer?\ CORRECT ANSWER IS Partial thickness skin loss involving epidermis and/or dermis What is a Stage III Ulcer?\ CORRECT ANSWER IS Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down, but not through, the underlying fascia What is a Stage IV Ulcer?\ CORRECT ANSWER IS Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. Eschar, yellow sloughing What is undermining?\ CORRECT ANSWER IS Space hidden under the edges of a wound, test this by using sterile gloves and a sterile Q-tip In Stage 3 and 4 What is tunneling of a wound?\ CORRECT ANSWER IS A tunnel in a wound In stage 3 and 4 How is bioengineered skin used to heal a pressure ulcer?\ CORRECT ANSWER IS It is sutured onto the wound and acts like a skin graft and sometimes it is only hope for healing the wound When is a pressure ulcer unstageable?\ CORRECT ANSWER IS When the ulcer is covered with slough or eschar ad it needs to be removed before staging can occur. What might a deep tissue injury look like?\ CORRECT ANSWER IS purple/maroon localized area of intact skin or blood filled blister What does T.I.M.E. principles of Wound Bed Preparation stand for?\ CORRECT ANSWER IS T - tissue I - Inflammation M - Moisture E - Edges

True or False: when there is nonviable(dead) or not intact tissue, it needs to be removed.\ CORRECT ANSWER IS True, you would remove it by the process debridement True or False: when inflammation is present around a wound there is no need to use antibacterial ointments.\ CORRECT ANSWER IS False, this may be necessary to treat the wound True or False: there is a delicate balance between a wound being to wet or to dry.
CORRECT ANSWER IS True, if it is to dry you need to add moisture but if it is to wet(draining) you must find a way to absorb it How can you tell if a wound is healing?\ CORRECT ANSWER IS Look at the edges of the wound and see if the cells are moving across the wound and getting smaller. What does D.I.M.E. stand for?\ CORRECT ANSWER IS D - debridement I - infection/inflammation M - Moisture Balance E - Edge/Environment Supportive Products Step by step, how do you treat and heal a wound?\ CORRECT ANSWER IS 1. Get rid of dead tissue

2. Identify and eliminate infection
3. Obliterate dead space
4. Absorb excess exudate
5. Maintain a moist wound surface
6. Provide thermal insulation
7. Protect from trauma or bacterial invasion What is the difference between a primary and secondary dressing?\ CORRECT ANSWER IS Primary would be placed first, inside the wound and the secondary would be on top of the primary. What are otolytic dressing?\ CORRECT ANSWER IS Over a long period of time the body will naturally with with the dressing and loosen the tissue so that when you change the dressing the tissue will be removed. Does not require a physicians order What is Enzyme treatment?\ CORRECT ANSWER IS collagenase, digests the necrotic tissue. Requires a physicians order What is mechanical debridement?\ CORRECT ANSWER IS 19g angiocath and connect to 35mm syringe and squirt it in the wound to wash the dead tissue out What is biological debridement?\ CORRECT ANSWER IS Using sterile maggots

What is whirlpool debridement?\ CORRECT ANSWER IS Getting in the whirlpool tub and allowing the hot water to loosen up the tissue. What are some questions to ask before selecting a dressing?\ CORRECT ANSWER IS What does the wound/patient need? What is available? What is practical? Describe the uses for a transparent film(Tegaderm, Op-site)?\ CORRECT ANSWER IS Autolytic debridement Used for a dry necrotic wound Partial thickness wound Preventative for friction Transparent films are contraindicated with...\ CORRECT ANSWER IS Exudate wounds, wounds with sinus tracts because this could cause maceration Describe the uses for Hydrocolloid dressings(Duoderm)?\ CORRECT ANSWER IS Looks like skin Autolytic debridement Partial thickness or shallow full thickness Keeps the wound moist and warm There will be a foul odor with this dressing Hydrocolloid dressings are contraindicated with...\ CORRECT ANSWER IS Heavily exudate, draining wounds Describe the uses for Absorption dressing?\ CORRECT ANSWER IS Autolytically debrides Absorbs large volumes Can be used to stuff into the dead space(eliminating the dead space) Spongelike Maintains a moist surface Used for draining wounds Sponge-like Absorption dressings are contraindicated with...\ CORRECT ANSWER IS Dry, necrotic wounds What is calcium alginate?\ CORRECT ANSWER IS Made out of ground seaweed and is able to absorb and eliminate dead space. Is gel like when removed. Required a dressing over the top. What is the purpose of a hydrogel dressing?\ CORRECT ANSWER IS Used for any thickness wound Used to ADD moisture

DO NOT USE FOR DRAINING WOUNDS

Autolytic debridement Used for dry wounds What is the purpose gauze?\ CORRECT ANSWER IS Fills wounds, absorbs. Used on mostly surgical wounds and not chronic wounds Not the number 1 choice What is impregnated gauze used for?\ CORRECT ANSWER IS Can be used for tunneling/undermining can be non-adherant Xeroform True or False: Enzymes work in a dry environment.\ CORRECT ANSWER IS False! You would need to add moisture. What are the secondary signs of infection?\ CORRECT ANSWER IS Delayed healing, change in color/wound bed, friable granulation tissue, absent/abnormal granulation tissue, increase/abnormal What is the purpose of an antimicrobial dressing?\ CORRECT ANSWER IS The healing process has slowed/stop There may be an infection forming Bacteria What is action of the silver antimicrobial dressing?\ CORRECT ANSWER IS Creates a gel as it absorbs wound drainage wound drainage activates silver and antimicrobial action begins used on burns and select wounds What are Iodine dressings used for?\ CORRECT ANSWER IS Reduces microbial burden including MRSA, no harmful effects on cells Absorbs slough, debris and exudate to clean the wound bed CONTRAINDICATED in patients with thyroid disease What is the purpose of the Negative pressure wound therapy vacuum assisted closure?
CORRECT ANSWER IS Helps to contract the wound, sucks out the dead tissue and exudate, helps with migration of the edges of the wound Advanced therapy What are the vacuum assisted closures used for?\ CORRECT ANSWER IS Chronic open wounds dehisced surgical wounds stage III and IV pressure ulcers

Vacuum assisted closures are contraindicated with...\ CORRECT ANSWER IS Cancer in the wound or surrounding tissues Fistulas Necrotic Tissue Untreated osteomyelitis How often does a vacuum assisted closure need to be changed?\ CORRECT ANSWER IS about three times a day True or False: If vacuum is stopped for 2 or more hours, the dressing needs to be changed.\ CORRECT ANSWER IS True True or False: Dressings do not replace the basic principles of wound healing
CORRECT ANSWER IS TRUE, you need to investigate the cause and correct causative factors What is Hemosiderin ?\ CORRECT ANSWER IS staining due to the break down of red blood cells, usually seen between the ankle and the knee Seen in patients with venous insufficiency What are the common characteristics of venous ulcers?\ CORRECT ANSWER IS Irregular edges, may be partial or full thickness usually in gaiter area/medical malleolus beefy red/yellow slough large amount of exudate EDEMA Periwound skin will be macerated, crusted and scaling What are the common characteristics of arterial ulcers?\ CORRECT ANSWER IS well defined edges distal aspect of extremity, pressure points of foot minimal exudate faint halo erythema around periwound skin