Understanding Wound Healing and Pressure Ulcers, Exams of Nursing

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Wound Care terms and answers 2024

Primary Function of Skin Disruption\ CORRECT ANSWER IS Protection from trauma (mechanical, thermal, chemical, radiant) What are the results of impaired skin integrity?\ CORRECT ANSWER IS Loss of body fluids and risk for infection Skin Lesion\ CORRECT ANSWER IS Pathological or traumatic discontinuity of TISSUE Etiology: Skin Lesions\ CORRECT ANSWER IS Mechanical injuries, pathological changes, allergies, bites Primary Lesion\ CORRECT ANSWER IS Initial or first lesion to occur ex: mosquito bite Secondary Lesion\ CORRECT ANSWER IS Change in the primary lesion ex: scab that develops after you have scratched the mosquito bite Wound\ CORRECT ANSWER IS Disruption in the structure and function of the skin from bodily injury or disease Intentional Wounds\ CORRECT ANSWER IS Wounds that occur from surgical procedures or treatments Unintentional Wound\ CORRECT ANSWER IS Wound that occurs from accidental injuries or trauma, adverse effects of health care Open Wound\ CORRECT ANSWER IS An injury in which the skin is INTERRUPTED or disrupted, EXPOSING the tissue beneath. Closed Wound\ CORRECT ANSWER IS Bruising underneath the skin Clean Wound\ CORRECT ANSWER IS Wound that is created with CLEAN surgical instruments; Microbes have not entered the wound. Contaminated Wound\ CORRECT ANSWER IS Wound with presence of microorganisms, dirt, debris, exudate Acute Wound\ CORRECT ANSWER IS Wound that heals in orderly and timely process; i.e. surgical incision Chronic Wound\ CORRECT ANSWER IS Wound that heals slowly and has an insidious onset; i.e. DPU

Types of Wounds\ CORRECT ANSWER IS Open vs Closed Clean vs Contaminated Acute vs Chronic RYB Classification System\ CORRECT ANSWER IS Based on WOUND BED COLOR Red Wound Bed Color\ CORRECT ANSWER IS Granulating tissue (clean, healthy tissue) Yellow Wound Bed Color\ CORRECT ANSWER IS Slough (fibrous material of exudate) ;wound is not ready to heal yet Eschar Wound Bed\ CORRECT ANSWER IS Necrotic tissue (thick, leathery); tissue is nonhealing and needs to be removed Exudate\ CORRECT ANSWER IS Fluid and cells that have escaped from blood vessels during the inflammatory process Exudate: Serous\ CORRECT ANSWER IS Clear, plasma thats escaping from wound bed Exudate: Sanguinous\ CORRECT ANSWER IS Bloody drainage Exudate: Serosanguinous\ CORRECT ANSWER IS Mixture of plasma and RBCs Exudate: Purulent\ CORRECT ANSWER IS Pus, liquification of necrotic tissue (body is getting rid of debris) Types of Wound Healing\ CORRECT ANSWER IS Primary Intention vs Seconday Intention vs Tertiary Intention Primary Intention\ CORRECT ANSWER IS ~Wound edges are approximated (closed) by sutures, staples ~NO blood, debris, exudate ~Healing occurs in approx 14 days ~↓ risk for infection ~Little tissue lost, ↓ scarring Secondary Intention\ CORRECT ANSWER IS ~ i.e. chronic wounds, DPUs ~edges CANNOT be approximated ~Wound bed will fill with granulating tissue ~↑ risk of infection, tissue loss, contractures ~longer healing times Tertiary Intention\ CORRECT ANSWER IS ~Occurs with contaminated wounds ~Keeping a wound open for 3 to 5 days to let healing begin

~After infection clears, wound is closed with sutures Partial Thickness Wounds\ CORRECT ANSWER IS Involves the EPIDERMIS or PARTIAL thickness of the skin; SHALLOW wound (Scrapes) ~Inflammatory Response: occurs in first 24 hours ~Epithelialization ~Restablishment of epidermal layers Epithelialization\ CORRECT ANSWER IS PARTIAL THICKNESS wounds healing in which EPITHELIAL cells proliferate and migrate over the surface of the wound to re- establish the normal skin layers Full Thickness Wound\ CORRECT ANSWER IS Wound that extends into the dermis; i.e. pressure ulcers 3 Phases of Healing Phase I: Inflammatory\ CORRECT ANSWER IS Takes 3 days ~Hemostasis: CLOTS form a fibrin matrix ~Histamine release: results in VASODILATION ~Phagocytosis: LEUKOCYTES reach the wound (clean the wound bed) ~Formation of Collagen: fibroblasts synthesize COLLAGEN Purpose of Inflammatory Phase\ CORRECT ANSWER IS To control bleeding and cleans the wound Phase 2: Proliferative\ CORRECT ANSWER IS Takes 3-24 days ~Fills wound with granulation tissue ~Causes contraction of the wound ~Resurfaces the wound be epithelialization Purpose of Proliferative Phase\ CORRECT ANSWER IS Fill wound with connective tissue of collagen; Collagen provides structural integrity and strength Phase 3: Remodeling or Maturation\ CORRECT ANSWER IS Takes more than 1 year ~Collagen continues to reorganize and gain strength, may not achieve maximal strength for 2 years ~Wound strength never exceeds 80% of its pre-injury strength ~Scar tissue has less pigmented cells (melanocytes) Pressure Ulcer\ CORRECT ANSWER IS Any lesion caused by UNRELIEVED pressure that leads to damage of underlying tissue; Develops when soft tissue is COMPRESSED between BONY PROMINENCES and hard surfaces Patients at Risk for Pressure Ulcers\ CORRECT ANSWER IS ~Bed rest patients ~Incontinent patients ~Diabetic patients

~Paralyzed patients ~Cachetic patients ~Obese patients Stage 1: Pressure Ulcer\ CORRECT ANSWER IS INTACT skin with Non-blanchable erythema; persistent REDNESS, temperature changes, texture may be different Stage 2: Pressure Ulcer\ CORRECT ANSWER IS Abrasion; PARTIAL thickness skin loss; involves epidermis and dermis, SHALLOW crater Stage 3: Pressure Ulcer\ CORRECT ANSWER IS Full thickness skin loss or DEEP crater; epidermis and dermis is gone, DOES NOT go thru the fascia or expose bone, muscle or tendon Stage 4: Pressure Ulcer\ CORRECT ANSWER IS Full thickness skin loss with extensive destruction; goes thru the fascia and may involve muscles and bones Problems with Wound Healing\ CORRECT ANSWER IS Infection vs Hemorrhage vs Fistula vs Dehiscence vs Evisceration Infection\ CORRECT ANSWER IS Commonly occurs 36 to 72 hours after SURGERY but may take 5-7 fays for symptoms to appear POSTOPERATIVELY Signs and Symptoms of Infection\ CORRECT ANSWER IS General: fever, malaise, ↑ WBC Wound Site: change in consistency, redness, drainage, swollen, tender Predisposing Factors of Infection\ CORRECT ANSWER IS Obesity Debilitation Age Corticosteroids Radiation therapy Wound dehiscence Hemorrhage\ CORRECT ANSWER IS Bleeding from wound bed or site Cause: surgical drain, loose suture, infection Internal Hemorrhage\ CORRECT ANSWER IS Distention of body part, swelling, shock, BP is going ↓, ↓ urine output External Hemorrhage\ CORRECT ANSWER IS Change in drainage, check posterior to the wound

Fistula\ CORRECT ANSWER IS An abnormal passageway between an organ and external surface; Forms because tissue does not close, abcess, infection, injury or radiation Dehiscence\ CORRECT ANSWER IS Separation of wound edges; Obesity is main factor Evisceration\ CORRECT ANSWER IS Protrusion of the internal organs; EMERGENCY!!!! ~Cover bowel with NS and sterile dressing ~Check VS, IV access ~Semi-fowlers position Factors Affecting Wound Healing\ CORRECT ANSWER IS Pg 23 Braden Scale\ CORRECT ANSWER IS Used to assess risk for impaired skin integrity; 6 subscales: sensory perception, moisture, activity, mobility, nutrition, friction Areas to Assess: Bony prominences, nares, tongue, lips, drainage tubes, orthopedic devices Lower the score-> Higher the risk Assessment of Wound\ CORRECT ANSWER IS Location Size (L x W x D, face of clock) Color (wound bed) Surrounding skin (periwound) Temperature Drainage Wound Closure Pain Drainage: C.O.T.A\ CORRECT ANSWER IS C - Color (may identify the type of organism) Yellow - staph Greenish-blue - pseudomonas Beige - proteus Brownish - aerobic bacteria O - Odor T - Thickness A - Amount Wound Assessment: R.E.E.D.A\ CORRECT ANSWER IS R - Redness (erythema) E - Edema (induration) E - Echymosis (black and blue discoloration or bruising)

D - Drainage A - Approximation Adequate Nutrition: Intervention for Wound Healing\ CORRECT ANSWER IS Carbs, Fats, Calories - wound regeneration Copper, Vitamin A and B complex IRON - O₂transport PROTEIN - Collagen synthesis Vitamin C - Collagen synthesis, capillary repair Zinc - Collagen synthesis, immunity Irrigation: Intervention for Wound Healing\ CORRECT ANSWER IS Solutions: can damage newly developing cells (temporary) Normal Saline (preferred solution; physiologically compatible with our tissue) ~Cleansing around in incision or drain → always irrigate or wipe ~Clean from center → outward (Wound bed is the CLEANEST) Purpose of Dressing\ CORRECT ANSWER IS ~PROTECTION from contamination ~GAURD from injury ~Compression ~Medication application ~ABSORB drainage ~Debridement ~MAINTAIN MOIST ENVIRONMENT(enhances wound epitheliazation, helps wound heal faster with less scar tissue) Wound Care Products\ CORRECT ANSWER IS Gauze Transparent Dressings Hydrocolloid Dressings Hydrogel Alginates Exudate Absorbers Foam Gauze\ CORRECT ANSWER IS ~CHEAP, used with debridement ~Indications: Prevents trauma, decreases infection and exudate, moist environement for wound bed to heal ~Contraindications: Adheres to wound bed (take away new cells that are forming)

Dry Sterile Dressings\ CORRECT ANSWER IS Used for post-op or surgical wounds (absorb drainage) Wet to Dry Dressing\ CORRECT ANSWER IS Used LARGER OPEN wounds; Pack with damp gauze; absorbs exudate and as dressing DRYS out, it will debride wound (remove dead tissue) Wet to Moist Dressing\ CORRECT ANSWER IS The preferred method of healing; Works through 'autolytic debridement' Autolytic Debridement\ CORRECT ANSWER IS Uses body's ability to digest devitalized tissue; Allows macrophages and neutrophils to ↓ necrotic tissue (BODY HEALS ITSELF) Transparent Dressing\ CORRECT ANSWER IS VAPOR permeable but impermeable to BACTERIA; Allows VISUALIZATION of the wound Indications: superficial wounds, LIGHT exudate Contraindications: not for infected wounds with heavy exudate i.e.Tegaderm Hydrocolloid Dressing\ CORRECT ANSWER IS NON-PERMEABLE to WATER VAPOR and O₂; Creates a hypoxic wound bed, moist environment, promotes autolytic debridement Indications: PARTIAL thickness, LIGHT exudate Contraindications: not for heavy exudate i.e. Duoderm Hydrogel\ CORRECT ANSWER IS Used to maintain a moist environment; POLYMER GELS Indications: COOL wounds, used in BURNS, PARTIAL thickness wounds Contraindications: cannot be used with heavy exudate i.e. Elasto-Gel Alginates\ CORRECT ANSWER IS Made from SEAWEED; ABSORBS exudates and aids in debridement Indications: PARTIAL or FULL thickness wounds, absorbs 20x its weight Contraindications: can be DRYING i.e. Aquacell Exudate Absorbers\ CORRECT ANSWER IS CONFORMS to wound surface and ELIMINATES dead space; promotes debridement

Indications: For PACKING and ABSORBING Contraindications: not for light exudate, may cause MACERATION Foam\ CORRECT ANSWER IS BACTERIA and WATER proof; Creates a moist environment Indications: PARTIAL to FULL thickness wounds, HEAVY exudate Contraindications: not for wounds with little exudate i.e. Mepilex Draining the Wound\ CORRECT ANSWER IS Prevents fluid from collecting Common Drains ~Penrose; small, flat latex tube ~Hemovac: closed drainage system which creates a vacuum (500 mL) ~Jackson-Pratt: closed drainage system which creates a vacuum (100-200 mL) Vacuum Assisted Closure\ CORRECT ANSWER IS Controlled negative pressure that is applied to a special wound dressing ~↑ CELL PROLIFERATION(caused by mechanical stretch of cells and growth) ~REDUCES periwound edema, removes fluid and speeds up healing (fluid in wound bed prevents adequate blood flow, impairs wound healing ~Provides a protected wound bed; Semiocclusive dressing keeps wound bed moist Candidates: Vacuum Assisted Closure\ CORRECT ANSWER IS ~Must tolerate for 22 hours ~have good nutrition, free from necrotic tissue Wounds: Vacuum Assisted Closure\ CORRECT ANSWER IS Traumatic Wounds Surgical Wounds Dehiscenced Wounds Pressure Ulcers Chronic Wounds Basic Dressing: Vacuum Assisted Closure\ CORRECT ANSWER IS Polyurethane sponge covered w/ transparent dressing Continuous vs Intermittent Therapy\ CORRECT ANSWER IS On for 5 minutes and off for 2 minutes (most aggressive) Intermittent is most painful Debridement\ CORRECT ANSWER IS Removal of contaminated or dead tissue and foreign matter from an open wound to promote healing

Sharp Debridement\ CORRECT ANSWER IS Removal of necrotic tissue from healthy areas of wound with sterile scissors, forceps and other instruments. Mechanical Debridement\ CORRECT ANSWER IS Involves physical removal of debris from a deep wound. Wet-to-dry, packed with moist gauze Enzymatic Debridement\ CORRECT ANSWER IS Removal of necrotic tissue by enzymes (Seen in PVD patients) Culturing a Wound\ CORRECT ANSWER IS Identify organisms Guidelines: rinse or irrigate wound to remove surface bacteria Swabbing vs Aspiration CDC recommends: fluid through needle aspiration or tissue biopsy OSU: Cleanse wound with NS, massage wound edges for flesh exudate, zig-zag swabbing of exudate Wound Care Procedure\ CORRECT ANSWER IS ~Assemble all dressing change supplies ~Assess the wound ~Set up your sterile field ~Pack the wound ~Secure the wound ~Label the dressing