skills quiz wounds

Braden Scale

Assesses a patient's risk of developing a pressure injury (skin breakdown).

Sensory perception

Ability to feel and respond to pressure or discomfort.

Moisture

How often the skin is exposed to moisture, such as urine or sweat.

Activity

How much the patient walks or moves around.

Mobility

Ability to change and control body position.

Nutrition

Adequacy of nutritional intake.

Friction and shear

Skin damage caused by rubbing or sliding.

Total score interpretation

Score of 6-23; lower score = higher risk, higher score = lower risk.

Very high risk score

A score of 9 or below indicates very high risk.

Primary intention

Clean wound with little tissue loss; edges approximated using sutures, staples, or adhesive.

Secondary intention

Large wound with considerable tissue loss; edges cannot be approximated.

Tertiary intention

Wound initially left open to resolve infection, then closed later.

Factors affecting wound healing

Nutritional status, age, body build, chronic illness, immune status, oxygenation and circulation, wound conditions, medications.

Wound assessment

Assess location, appearance, periwound, size, drainage, pain, dressing, complications, sutures, drains, and tubes.

Wound measurement

Measure length × width × depth in centimeters.

Tunneling

A narrow passage extending deeper into the wound.

Undermining

Tissue destruction underneath the wound edges.

Dehiscence

Partial or total separation of a previously closed wound.

Evisceration

Protrusion of internal organs or tissues through an opened wound; a surgical emergency.

Serous drainage

Clear, watery drainage usually consisting of serum and inflammatory fluid.

Sanguineous drainage

Bright red or bloody drainage indicating active bleeding.

Serosanguineous drainage

Thin, watery, pale red or pink drainage; a mixture of serum and blood.

Purulent drainage

Thick drainage that may be yellow, green, tan, or brown; may indicate infection.

Wound culture purpose

Identify the microorganism causing infection for appropriate treatment selection.

Ostomy

A surgically created opening from an internal organ to the outside of the body.

Stoma

The portion of the ostomy visible at the skin.

Peristomal skin

The skin surrounding the stoma.

Normal stoma findings

Pink or dark red, moist, minimal bleeding during gentle cleansing, mild edema for approximately 6-8 weeks after surgery, usually protrudes about 0.5-1 inch from the skin.

Abnormal stoma findings

Dark purple or blue, pale or unusually white appearance, excessive bleeding, peristomal skin irritation or breakdown, persistent leakage, signs of obstruction or significant changes in output.

Priority finding in stoma assessment

A dark purple or blue stoma may indicate impaired blood supply and requires immediate follow-up.

Ostomy complications

Peristomal skin irritation and breakdown, infection, ischemia or necrosis from inadequate blood supply, retraction, prolapse, parastomal hernia, obstruction or reduced output, leakage and poor appliance fit, dehydration and electrolyte imbalances.

Emptying the pouch

Empty when the pouch is approximately one-third to one-half full to prevent leakage and pulling on the skin.

Changing the appliance

Change approximately every 3-7 days or sooner if leaking, clean the peristomal skin, assess the stoma, apply a skin barrier, fit and apply the new pouch securely.

Patient education for ostomy care

Teach the patient to empty and change the pouch, assess stoma and peristomal skin, explain signs of complications, encourage independence and self-care.

Dietary considerations for ostomy patients

Chew food thoroughly, maintain adequate hydration, some foods may increase gas or odor, and some may thicken or loosen output.

Location of fecal ostomy and stool consistency

Ascending colostomy: Liquid stool; Transverse colostomy: Unformed or loose stool; Descending colostomy: Semiformed stool; Sigmoid colostomy: Formed stool; Ileostomy: Generally liquid to semiliquid stool.

Penrose drain

Hollow, open-ended rubber tube used after surgery or to drain an abscess.

Jackson-Pratt (JP) drain

Closed drainage system with a bulb that creates gentle suction when compressed.

Hemovac

Closed-suction drain with a spring-like collection reservoir, often used when postoperative blood drainage is expected.

Wound VAC (negative-pressure wound therapy)

Applies negative pressure to the wound, removes excess wound fluid, maintains a suitable moist wound environment.

T-tube

Placed in the common bile duct after certain biliary surgeries to drain bile.

General drain troubleshooting

Check for kinks, compression, disconnections, and accidental pulling; observe the amount, color, and consistency of drainage.

Sterile technique

Maintains a sterile field and uses sterile supplies and gloves.

Clean technique

Uses clean gloves and clean supplies to reduce contamination.

Pain management

Assess pain before beginning and administer prescribed pain medication early enough for it to work.

General dressing-change process

Verify the order and identify the correct wound, explain the procedure, provide privacy, and position the patient.

Wound irrigation

Goal: Remove debris and contaminants without causing tissue damage or unnecessary pain.

Dry dressings

Often used for wounds with little drainage to protect the wound from contamination.

Wet-to-dry dressings

May be used for selected wounds requiring mechanical debridement when specifically ordered.

Hydrocolloid dressings

Used for shallow to moderate-depth wounds with minimal to moderate drainage.

Montgomery straps

Used when dressings need to be changed frequently to reduce repeated adhesive removal and skin irritation.

Evidence-based practice (EBP)

Means using the best available evidence to guide clinical decisions.

Plagiarism

Presenting someone else's words, ideas, or work as your own without proper acknowledgment.

Citations

Required when directly quoting someone else's words or paraphrasing information from a source.

Avoiding plagiarism

Cite the original source and use quotation marks for direct quotes.

Wound irrigation with healthy granulation tissue

Irrigate gently to remove debris without damaging healthy tissue.

Abnormal stoma finding

A dark purple or blue stoma may indicate impaired blood supply.

Ileostomy output

Liquid to semiliquid stool because the output comes from the small intestine.

Greatest risk for pressure injury

A patient with limited mobility, frequent moisture exposure, and poor nutritional intake is at greatest risk because pressure, moisture, and poor nutrition contribute to skin breakdown.

Factors affecting wound healing

Nutritional status, age, oxygenation and circulation, immune status, chronic illness, and medications all affect wound healing.

Secondary intention

Healing of a large wound with significant tissue loss and unapproximated edges. Granulation tissue fills the wound as it heals.

Evisceration

Protrusion of internal organs through an opened wound. Cover the exposed organs with sterile dressings moistened with sterile normal saline and notify the surgeon immediately. Never push the organs back inside.

Wound measurement

Measure wounds in centimeters using the sequence length × width × depth. Length is head-to-toe, width is side-to-side, and depth is the deepest point.

Wound irrigation with healthy granulation tissue

Irrigate gently to remove debris without damaging healthy tissue or causing bleeding.

Montgomery straps

Straps used to secure dressings when frequent changes are necessary. They reduce repeated adhesive removal and skin irritation.