NURS3802 Module 12: Wound Care Basics

What are the functions of skin?

- protection from UV light via melanocytes

- protection from outside contamination

- sensation of pain, touch, temperature, and pressure

- thermoregulation

- vitamin D synthesis

What compromises skin function and wound healing?

- tissue perfusion

- oxygenation

- nutrition status, especially protein

- thinning skin due to aging

- diseases such as cardiovascular, respiratory, diabetes, and immunocompromised

- medications like steroids

- fever

- sun exposure

- hydration status

- obesity

- smoking

- edema

Why does obesity compromise skin function and wound healing?

adipose tissue secretes pro-inflammatory cytokines which can impair the normal healing process

Why does smoking compromise skin function and wound healing?

smoking causes vasoconstriction which prevents blood flow

Why does edema compromise skin function and wound healing?

decreases tissue perfusion

What are the layers of skin from the outside of the body in?

- epidermis

- dermis

- subcutaneous fat

What are the 3 different types of wound healing?

- primary intention

- secondary intention

- tertiary intention

What wounds heal by primary intention?

wounds that were surgically closed

What wounds heal by secondary intention?

- chronic wounds

- pressure ulcers

- surgical wounds left open

What wounds heal by tertiary intention?

wounds that had delayed surgical closure

What are the 3 different phases of wound healing?

- inflammatory

- proliferative

- maturation

What are the 5 classic signs of the inflammatory phase of wound healing?

- heat

- redness

- pain

- swelling

- fever

Granulation tissue is formed during which phase of wound healing?

proliferative

What can occur if the healing ridge is not seen at day 5-7?

the wound will be at risk for dehiscence

What is the purpose of the maturation phase of wound healing?

strengthen and remodel the granulation tissue

During which phase of wound healing are collagen fibers reorganized to form a lattice-type structure?

maturation phase

What should be assessed and documented pertaining to wounds?

- type/classification

- etiology

- location

- measurement

- appearance

- shape

- pain

- overall physical health of the patient

What are examples of healthy tissue types found in a wound?

- granulation tissue

- epithelial tissue

- epithelial bridging

What are 2 types of necrotic tissue?

- eschar

- slough

What is "stuck" tissue?

tissue that is stuck in the proliferative phase that is clean but non-granulating

How long does it take for a wound to be considered chronic?

2 weeks without progress

What is eschar?

black dead tissue

What is slough?

tan, yellow, or green scab like material

How is a wound measured?

- length: head to toe dimension

- width: side to side; greatest width perpendicular to the length

- depth: from skin surface to the deepest area of safe probe

When should a wound never be probed for depth measurement?

if it has possible exposed major vasculature or exposed organs

What is the periwound skin?

skin 4cm around the wound

Describe maceration.

the softening and breaking down of skin resulting from prolonged exposure to moisture

Describe denudation.

a condition of losing an outside layer, such as the epithelium of the skin

What is excoriation?

superficial traumatic abrasions and scratches which remove some of the skin

When should the odor of a wound be assessed?

after cleaning or irrigating the wound with wound cleanser or NS

Describe sanguineous exudate.

- red

- thin and watery

- due to disruption of blood vessels

Describe serosanguineous exudate.

- light red to pink

- thin and watery

- normal during the inflammatory and proliferative phases of healing

Describe serous exudate.

- clear to straw color

- thin and watery

- normal during the inflammatory and proliferative phases of healing

Describe seropurulent exudate.

- cloudy, yellow to tan

- thin and watery

- may be the first sign of an impending wound infection

Describe purulent exudate.

- yellow, brown, or tan

- thick and opaque

- signals wound infection

What are pressure injuries?

any lesion caused by unrelieved pressure that results in damage to underlying tissue

What are factors for development of a pressure injury?

- friction

- shear

- moisture

- chemicals

- nutrition

- age

- disease

- medications

- co-morbidities

How can skin breakdown be prevented?

- minimize pressure, friction, and sheer forces

- prevent excessive moisture or dryness at the skin surface

- increase delivery of nutrients through dietary and tissue perfusion interventions

What is the #1 risk for pressure injuries?

dementia

What does a deep tissue injury look like?

- purple or maroon

- intact skin

- blood-filled blister

Which of the following is a sign of infection in a wound?

a. A decrease in the amount of wound drainage

b. Redness, warmth, and increased pain around the wound

c. The wound healing with healthy granulation tissue

d. A decrease in the size of the wound

b. Redness, warmth, and increased pain around the wound

Which best describes a fresh surgical wound that has been closed with sutures or staples making the two edges of the wound meet?

a. Approximated

b. Proliferated

c. Debrided

d. Tertiary intention

a. Approximated

The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?

a. Stratum germinativum

b. Epidermis

c. Subcutaneous layer

d. Stratum corneum

c. Subcutaneous layer

The nurse recognizes that the cause of pressure ulcers includes which factors? (Select all that apply.)

a. Intensity of the pressure

b. Duration of the pressure

c. Tissue's ability to tolerate the pressure

d. Person's age

e. Person's nutritional status

a. Intensity of the pressure

b. Duration of the pressure

c. Tissue's ability to tolerate the pressure

d. Person's age

e. Person's nutritional status

A client who has been confined to a hospital bed for the past 2 weeks complains of sores on the buttocks. On examination, the nurse quickly determines that the sores are caused by unrelieved compression of the skin that has resulted in damage to underlying tissues. This client is exhibiting signs of which of the following conditions?

a. pressure ulcers

b. jaundice

c. ecchymosis

d. ischemia

a. pressure ulcers

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "why is my wound still open? WIll it ever heal?" which of the following responses by the nurse is appropriate?

a. Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal

b. As soon as the infection clears, your surgeon will staple the wound closed

c. If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention

d. Your wound will heal slowly as granulation tissue forms and fills the wound

d. Your wound will heal slowly as granulation tissue forms and fills the wound

A nurse is explaining to a client that the client's skin in the perineal area has softened due to prolonged exposure to moisture from urinary incontinence. This condition is known as which of the following?

a. Maceration

b. Ecchymosis

c. Dehiscence

d. Necrosis

a. Maceration

You are applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate?

a. This wound is too large for a scab to form over it, so a moist dressing is the best alternative

b. Allowing a scab to form would prevent us from observing the wound for signs of infection

c. You may be correct. I will check with your PCP

d. Wounds heal better when a moist wound bed is maintained

d. Wounds heal better when a moist wound bed is maintained

Which of the following are clinical goals of wound care?

a. Assess patient & wound

b. Select appropriate products to manage wounds

c. Re-evaluate the plan as patient & wound characteristics change

d. All of the above

d. All of the above

Wounds that heal by ____ intention are left open for several days to allow for edema or infection to resolve and/or to all exudate to drain:

a. Primary

b. Secondary

c. Early

d. Tertiary

d. Tertiary

The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

a. Osteoarthritis

b. Glaucoma

c. Deafness

d. Diabetes mellitus

d. Diabetes mellitus

Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer?

a. Begin antibiotic therapy before the dressing change.

b. Use appropriate personal protective equipment.

c. Adhere to sterile technique during the intervention.

d. Complete the dressing change in an effective, efficient manner.

b. Use appropriate personal protective equipment.

The wound bed of a patient's pressure ulcer is red. What does this finding indicate to the nurse?

a. Necrotic

b. Presence of slough

c. Granulation tissue

d. Development of an infection

c. Granulation tissue

When receiving a report at the beginning of your shift, you learn that your assigned client has a surgical incision that is healing by primary intention. You know that your client's incision is:

a. Well approximated, with minimal or no drainage.

b. Going to take a little longer than usual to heal.

c. Going to have more scarring than most incisions.

d. Draining some serosanguineous drainage.

a. Well approximated, with minimal or no drainage.

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?

a. The patient ate two thirds of breakfast.

b. The patient has fecal incontinence.

c. The patient has a raised red rash on the right shin.

d. The patient's capillary refill is less than 2 seconds.

b. The patient has fecal incontinence.

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by

a. Tertiary intention.

b. Secondary intention.

c. Partial-thickness repair.

d. Primary intention.

d. Primary intention.

Which nursing observation would indicate that a wound healed by secondary intention?

a. Minimal scar tissue

b. Minimal loss of tissue function

c. Permanent dark redness at site

d. Scarring can be severe

d. Scarring can be severe

Which of the following is an example of a secondary intention wound healing process?

a. Healing of a surgical incision with sutures

b. Healing of a wound with a scab formation

c. Healing of a large wound with irregular edges left open

d. Healing of a wound with adhesive strips

c. Healing of a large wound with irregular edges left open

A nurse is preparing to clean a wound. Which action should the nurse take first?

a. Apply a new dressing

b. Assess the wound for any signs of infection

c. Wash hands and apply gloves

d. Remove the old dressing

c. Wash hands and apply gloves

Which of the following is a common consequence of poor tissue perfusion in wound healing?

a. Improved oxygenation of the wound

b. Increased risk of infection

c. Enhanced tissue regeneration

d. Enhanced granulation tissue formation

b. Increased risk of infection

Which phase of wound healing involves the formation of new capillaries and the migration of fibroblasts?

a. Inflammatory phase

b. Proliferative phase

c. Maturation phase

d. Remodeling phase

b. Proliferative phase

In the inflammatory phase of wound healing, which of the following occurs?

a. Reorganization of collagen fibers

b. Granulation tissue formation

c. Phagocytosis of bacteria and debris

d. Epithelial cell migration

c. Phagocytosis of bacteria and debris

Which type of tissue is found in the wound bed and is highly vascular, pink to dark red, and firm?

a. Granulation tissue

b. Slough

c. Eschar

d. Epithelial tissue

a. Granulation tissue

What is a key characteristic of necrotic tissue in a wound bed?

a. Red and firm with a shiny white covering

b. Soft, moist, and yellow to tan in color

c. Black, hard, and dry

d. Pink and healthy

c. Black, hard, and dry

What does "epibole" refer to when documenting wound edges?

a. Edges that are pink and healthy

b. Edges that are rolled under, preventing closure

c. Edges that are attached and firm

d. Edges that are hyperpigmented

b. Edges that are rolled under, preventing closure

Which of the following tissue types in the wound bed is at very high risk for re-opening due to its fragility?

a. Granulation tissue

b. Epithelial tissue

c. Scar tissue

d. Muscle

c. Scar tissue

What type of wound odor suggests the presence of infection?

a. Faint, earthy odor

b. No odor

c. Malodorous, foul smell

d. Sweet, fruity odor

c. Malodorous, foul smell

In which type of wound healing is there a greater risk of infection due to the edges not being approximated?

a. Primary Intention

b. Secondary Intention

c. Tertiary Intention

d. All of the above

b. Secondary Intention

Which type of wound healing is the fastest type of wound closure, has a low risk for infection, and heals with minimal scarring?

primary intention

Which phase of wound healing is the reactive phase?

inflammatory

Which phase of wound healing is the regenerative phase?

proliferative

Which phase of wound healing is the remodeling phase?

maturation