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Principles
Wound Care ATI 55
| Question | Answer |
|---|---|
| Wounds are a result of? | injury to the skin |
| What is a pressure ulcer? | a specific type of tissue injury caused by unreleieved pressure that results in ischemia and damage to the underlying tissue |
| Suspected deep tissue injury show? | discolored but intact skin |
| What is stage 1 pressure ulcer? | intact skin, non blanchable redness, typically over a bony prominence, tissue swollen, with darker skin the site appears blue or purple |
| What is stage 2 pressure ulcer? | partial thickness skin loss, involving epidermis and dermis, ulcer visible, may appear as an abrasion, blister, or shallow crater, edema present, possible drainage |
| What is stage 3 pressure ulcer? | full thickness tissue loss with damage to subQ tissue, deep crater without undermining of adjacent tissue, no muslce or bone exposed, drainage and infection are common |
| What is stage 4 pressure ulcer? | full thickness tissue loss with damage to sub Q tissue, damage to muscle, bone, and supporting structures, deep pockets of tunneling, infection, eschar, and slough |
| What is an unstagable ulcer? | ulcer whose stage cannot be determined because eschar or slough obscures the wound |
| What do the first 3 days of healing consist of? | inflammatory stage, control bleeding, deliver oxygen, WBC and nutrients to the area |
| What is the proliferative stage? | 3-24 days of wound healing |
| What happens during the proliferative stage? | replace lost tissue, contracting wound edges, resurfacing of new epithelial cells |
| What does the maturation or remodeling stage involve? | the strengthening of the collagen scar an the restoration of a more normal appearance. (can take 1 year) |
| What is the characteristics of primary intention healing? | little or no tissue loss, edges are approximated (surgical incision) |
| What type of wound goes with primary intention healing? | heals fast, low risk infection, no scarring |
| What are the characteristics of secondary intention healing? | loss of tissue, wound edges widely separated (pressure ulcer, stab wound) |
| What type of wound type goes with secondary intention healing? | longer healing time, increase risk of infection, and scarring |
| What are the characterisitics of tertiary intention healing? | widely separated, deep, spontaneous opening of previously closed wound, risk of infection |
| What is the wound types that goes with terieary intention of healing? | extensive drainage and tissue debris, closed later, long healing time |
| What are factors that affect wound healing? | age, wellness, immune function, meds, nutrition |
| Increased age delays healing because of? | loss of skin tugor, skin fragility, decreased peripheral circulation, slower tissue regeneration, decreased absorption of nutrients, decrease collagen |
| Fatty tissue lacks? | blood supply |
| smoking impairs? | oxygenation and clotting |
| Inflammation is a? | localized protective response triggered by injury or destruction of tissue |
| What are principles of wound care? | Assess, clean, protect |
| What does a red wound indicate? | healthy regeneration of tissue |
| What does a yellow wound indiate? | presence of purulent drainage |
| What does black wound indicate? | presence of eschar that stops healing process, must be removed |
| Drainage is? | a normal result of the healing process |
| How is the character of the drainage noted? | consistency, color, and odor |
| What is serous drainage? | portion of the blood that is watery and clear |
| What is sangineous drainage? | serum and RBC, thick and reddish |
| What is serosangineous drainage? | serum and blood, blood streaked |
| What is purulent drainage? | result of infection, thick and contain WBC, tiss debris, and bacteria, may have foul odor |
| What should a pt have during wound healing? | hydration and protein |
| What are preferred cleansing agents for wounds? | isotonic |
| What do woven gauze do? | absorbs exudate from the wound |
| What does nonadherent material do? | does not adhere to wound bed |
| What does self adhesive transperent film do? | is a temporary "second skin", for small superficial wounds |
| What is hydrocolloid? | occlusive dressing that swells in the presence of exudate |
| What is hydrogel used for? | infected deep wounds, provides moist wound bed |
| What is dehiscence? | partial or toatal rupture of a sutured wound, usually with separation of underlying skin layers |
| What is evisceration? | profusion of organs through opening |
| What are s/s of dehiscence? | increase in flow of fluid, straining, client report popping |
| What is the primary focus for prevention of pressure ulcers? | relieve pressure, and provide hydration and nutrition |
| How do you prevent pressure ulcers? | clean, dry skin and wrinkle free linens |
| What is shearing force? | sliding in bed |
Created by:
alicia.rennaker
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