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Questions and Answers
What is the main function of a dressing in wound care?
What is the main function of a dressing in wound care?
- To remove debris from the wound
- To cause further irritation to the wound
- To promote infection
- To prevent infection and promote wound healing (correct)
What is the primary cause of pressure injury?
What is the primary cause of pressure injury?
- Moist heat and humidity
- Tension and stress on the skin
- Pressure between a bony prominence and an external surface (correct)
- Friction and shearing forces
What is the characteristic of serosanguineous drainage?
What is the characteristic of serosanguineous drainage?
- Mixture of serum and RBC (correct)
- Clear and watery
- Thick and yellow
- Dark yellow or green
What is the purpose of heat therapy in wound care?
What is the purpose of heat therapy in wound care?
What type of wound is characterized by a foreign object entering the skin or mucous membrane?
What type of wound is characterized by a foreign object entering the skin or mucous membrane?
What is the primary characteristic of eschar?
What is the primary characteristic of eschar?
What is the purpose of irrigating wounds from top to bottom?
What is the purpose of irrigating wounds from top to bottom?
What is the main difference between serous and purulent drainage?
What is the main difference between serous and purulent drainage?
What is the most serious complication of dehiscence?
What is the most serious complication of dehiscence?
What does yellow indicate in wound healing?
What does yellow indicate in wound healing?
What is the main purpose of repositioning in wound care?
What is the main purpose of repositioning in wound care?
What is the range of hemoglobin levels in a healthy individual?
What is the range of hemoglobin levels in a healthy individual?
What is the primary intention of wound healing?
What is the primary intention of wound healing?
What is the term for the partial or total separation of a wound?
What is the term for the partial or total separation of a wound?
Moist heat helps remove debris from a wound.
Moist heat helps remove debris from a wound.
Pressure injury develops in bone tissue.
Pressure injury develops in bone tissue.
Dehiscence is the most serious complication of evisceration.
Dehiscence is the most serious complication of evisceration.
A wound dressing prevents infection.
A wound dressing prevents infection.
Fever is not a sign of infection in a wound.
Fever is not a sign of infection in a wound.
Wound healing by secondary intention takes less time to heal.
Wound healing by secondary intention takes less time to heal.
NERDS is an acronym used to describe a certain type of wound.
NERDS is an acronym used to describe a certain type of wound.
Red dressing is used to protect the wound.
Red dressing is used to protect the wound.
Cold therapy is used to reduce muscle tension.
Cold therapy is used to reduce muscle tension.
Yellow dressing indicates the need for wound healing.
Yellow dressing indicates the need for wound healing.
Black dressing indicates eschar and requires removal.
Black dressing indicates eschar and requires removal.
Serosanguineous drainage is a mixture of serum and white blood cells.
Serosanguineous drainage is a mixture of serum and white blood cells.
The normal range of hemoglobin level is between 10-16.
The normal range of hemoglobin level is between 10-16.
A penetrating wound is caused by a blunt instrument.
A penetrating wound is caused by a blunt instrument.
Moist heat helps soften and remove ______ from a wound.
Moist heat helps soften and remove ______ from a wound.
Pressure injury develops in ______ tissue.
Pressure injury develops in ______ tissue.
A function of a dressing is to prevent ______.
A function of a dressing is to prevent ______.
Signs and symptoms of infection include ______.
Signs and symptoms of infection include ______.
NERDS is an acronym used to describe a ______ wound.
NERDS is an acronym used to describe a ______ wound.
STONEES is an acronym used to describe ______ in wound care.
STONEES is an acronym used to describe ______ in wound care.
Heat therapy reduces ______ tension.
Heat therapy reduces ______ tension.
Purulent drainage is characterized by a ______ odor.
Purulent drainage is characterized by a ______ odor.
Evisceration is a complication of _______________
Evisceration is a complication of _______________
Wound healing by _______________ intention takes longer to heal
Wound healing by _______________ intention takes longer to heal
Skin redness is also known as _______________
Skin redness is also known as _______________
Interventions for skin breakdown include _______________ and reposition
Interventions for skin breakdown include _______________ and reposition
Factors that affect healing include _______________ and nutritional status
Factors that affect healing include _______________ and nutritional status
The normal range of hemoglobin levels is between _______________
The normal range of hemoglobin levels is between _______________
What helps soften and remove crust in wound care?
What helps soften and remove crust in wound care?
What type of wound develops in soft tissue?
What type of wound develops in soft tissue?
What is a function of a dressing in wound care?
What is a function of a dressing in wound care?
What are signs and symptoms of infection in a wound?
What are signs and symptoms of infection in a wound?
What does NERDS stand for in wound care?
What does NERDS stand for in wound care?
What is the purpose of heat therapy in wound care?
What is the purpose of heat therapy in wound care?
What is the characteristic of purulent drainage?
What is the characteristic of purulent drainage?
What is eschar?
What is eschar?
What is the result of dehiscence?
What is the result of dehiscence?
What is the purpose of yellow dressings in wound healing?
What is the purpose of yellow dressings in wound healing?
What is a factor that affects wound healing?
What is a factor that affects wound healing?
What is the term for wound healing that occurs naturally, without surgical intervention?
What is the term for wound healing that occurs naturally, without surgical intervention?
What is the term for skin redness?
What is the term for skin redness?
What is an intervention for skin breakdown?
What is an intervention for skin breakdown?
Flashcards
Moist Heat
Moist Heat
Softens and removes crust from wounds.
Pressure Injuries
Pressure Injuries
Develops when soft tissue is compressed between a bony prominence and an external surface.
Functions of a Dressing
Functions of a Dressing
Prevent infection, promote healing, and protect the wound.
Infection Signs/Symptoms
Infection Signs/Symptoms
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NERDS (Wound Assessment)
NERDS (Wound Assessment)
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STONEES (Wound Assessment)
STONEES (Wound Assessment)
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Heat Therapy
Heat Therapy
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Cold Therapy
Cold Therapy
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Serous Drainage
Serous Drainage
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Sanguineous Drainage
Sanguineous Drainage
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Serosanguineous Drainage
Serosanguineous Drainage
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Purulent Drainage
Purulent Drainage
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Penetrating Wound
Penetrating Wound
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Contusion
Contusion
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Laceration
Laceration
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Abrasion
Abrasion
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Eschar
Eschar
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Puncture Wound
Puncture Wound
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Evisceration
Evisceration
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Erythema
Erythema
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Dehiscence
Dehiscence
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Secondary Intention Healing
Secondary Intention Healing
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Red Wound Treatment
Red Wound Treatment
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Yellow Wound Treatment
Yellow Wound Treatment
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Black Wound Treatment
Black Wound Treatment
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Skin Breakdown Interventions
Skin Breakdown Interventions
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Factors Affecting Healing
Factors Affecting Healing
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Primary Intention
Primary Intention
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Secondary Intention
Secondary Intention
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Tertiary Intention
Tertiary Intention
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Study Notes
Wound Care and Healing
- Moist heat helps soften and remove crust from wounds.
- Pressure injuries develop in soft tissue, compressed between a bony prominence and external surface.
Functions of a Dressing
- Infection prevention
- Wound healing promotion
- Protection of the wound
Signs and Symptoms of Infection
- Fever
- Redness
- Swelling
- Odor
- Malaise
- Increased pain
- Elevated pulse
- Elevated blood pressure
Wound Classification
NERDS
- N: Non-healing wound
- E: Exudative wound (leaking)
- R: Red and bleeding wound
- D: Debris from wound
- S: Smell from wound
STONEES
- S: Size is bigger
- T: Temp increased
- O: Exposed Bone
- N: New areas of breakdown
- E: Exudate (fluid that leaks)
- E: Erythema, edema
- S: Smell
Wound Irrigation and Heat Therapy
- Irrigate wounds from top to bottom
- Heat therapy:
- Reduces muscle tension
- Treats infections
- Used for surgical wounds
- Inflamed tissue
- Arthritis
- Joint pain
Cold Therapy
- Reduces inflammation
- Reduces muscle spasm
- Produces numbness
Wound Drainage
- Serous drainage: clear, watery
- Sanguineous drainage: large number of RBC, looks like blood
- Serosanguineous drainage: mixture of serum and RBC, light pink in color
- Purulent drainage: WBC liquified, dead tissue debris, dead and alive bacteria, thick, musty, foul odor, dark yellow or green
Types of Wounds
- Penetrating wound: foreign object entering skin or mucous membrane, lodging in underlying tissue
- Contusion: blunt instrument, overlying skin intact with injury to underlying soft tissue, hematoma
- Laceration: tearing of skin and tissue with blunt or irregular instrument, tissue not aligned, loose flaps
- Abrasion: friction, rubbing or scraping epidermis, dirt and germs possible
- Eschar: necrotic, red tissue, delays wound healing, looks dry, black and leathery
- Puncture wound: blunt or sharp instrument punctures skin
- Evisceration: most serious complication of dehiscence, primary with ABD surgeries, wound completely separates
Wound Healing
- Erythema: skin redness
- Dehiscence: partial or total separation of wound, result of stress
- Wound healing by secondary intention:
- Takes longer to heal
- Left open
- Heals by itself
- Fills in and closes naturally
- Red: protect, in the proliferative stage of healing, needs gentle cleaning, moist dressings, only change when necessary
- Yellow: cleanse, indicates drainage, requires wound healing, oozing from tissue, cleaning and irrigating
- Black: debride, indicates eschar, black, brown, grey, requires removal, after debridement moves to yellow
Interventions for Skin Breakdown
- Reposition
- Wool barriers
- Antiseptic sprays
- Lotions
- Emollient
- Fluid status
- Nutritional status
- Assessments
- Pressure mattress
- Mobilization
- Maintain HOB
Factors that Affect Healing
- Age
- Medication
- Comorbidities
- Nutritional status
- Circulation
- Wound care
- Immunosuppression
Wound Closure
- Primary intention: superficial, surgical, burns
- Secondary intention: wounds that are infected
- Tertiary intension: delayed primary closure
Hemoglobin Range
- 12-18
Wound Care and Healing
- Moist heat helps soften and remove crust from wounds.
- Pressure injuries develop in soft tissue, compressed between a bony prominence and external surface.
Functions of a Dressing
- Infection prevention
- Wound healing promotion
- Protection of the wound
Signs and Symptoms of Infection
- Fever
- Redness
- Swelling
- Odor
- Malaise
- Increased pain
- Elevated pulse
- Elevated blood pressure
Wound Classification
NERDS
- N: Non-healing wound
- E: Exudative wound (leaking)
- R: Red and bleeding wound
- D: Debris from wound
- S: Smell from wound
STONEES
- S: Size is bigger
- T: Temp increased
- O: Exposed Bone
- N: New areas of breakdown
- E: Exudate (fluid that leaks)
- E: Erythema, edema
- S: Smell
Wound Irrigation and Heat Therapy
- Irrigate wounds from top to bottom
- Heat therapy:
- Reduces muscle tension
- Treats infections
- Used for surgical wounds
- Inflamed tissue
- Arthritis
- Joint pain
Cold Therapy
- Reduces inflammation
- Reduces muscle spasm
- Produces numbness
Wound Drainage
- Serous drainage: clear, watery
- Sanguineous drainage: large number of RBC, looks like blood
- Serosanguineous drainage: mixture of serum and RBC, light pink in color
- Purulent drainage: WBC liquified, dead tissue debris, dead and alive bacteria, thick, musty, foul odor, dark yellow or green
Types of Wounds
- Penetrating wound: foreign object entering skin or mucous membrane, lodging in underlying tissue
- Contusion: blunt instrument, overlying skin intact with injury to underlying soft tissue, hematoma
- Laceration: tearing of skin and tissue with blunt or irregular instrument, tissue not aligned, loose flaps
- Abrasion: friction, rubbing or scraping epidermis, dirt and germs possible
- Eschar: necrotic, red tissue, delays wound healing, looks dry, black and leathery
- Puncture wound: blunt or sharp instrument punctures skin
- Evisceration: most serious complication of dehiscence, primary with ABD surgeries, wound completely separates
Wound Healing
- Erythema: skin redness
- Dehiscence: partial or total separation of wound, result of stress
- Wound healing by secondary intention:
- Takes longer to heal
- Left open
- Heals by itself
- Fills in and closes naturally
- Red: protect, in the proliferative stage of healing, needs gentle cleaning, moist dressings, only change when necessary
- Yellow: cleanse, indicates drainage, requires wound healing, oozing from tissue, cleaning and irrigating
- Black: debride, indicates eschar, black, brown, grey, requires removal, after debridement moves to yellow
Interventions for Skin Breakdown
- Reposition
- Wool barriers
- Antiseptic sprays
- Lotions
- Emollient
- Fluid status
- Nutritional status
- Assessments
- Pressure mattress
- Mobilization
- Maintain HOB
Factors that Affect Healing
- Age
- Medication
- Comorbidities
- Nutritional status
- Circulation
- Wound care
- Immunosuppression
Wound Closure
- Primary intention: superficial, surgical, burns
- Secondary intention: wounds that are infected
- Tertiary intension: delayed primary closure
Hemoglobin Range
- 12-18
Wound Care and Healing
- Moist heat helps soften and remove crust from wounds.
- Pressure injuries develop in soft tissue, compressed between a bony prominence and external surface.
Functions of a Dressing
- Infection prevention
- Wound healing promotion
- Protection of the wound
Signs and Symptoms of Infection
- Fever
- Redness
- Swelling
- Odor
- Malaise
- Increased pain
- Elevated pulse
- Elevated blood pressure
Wound Classification
NERDS
- N: Non-healing wound
- E: Exudative wound (leaking)
- R: Red and bleeding wound
- D: Debris from wound
- S: Smell from wound
STONEES
- S: Size is bigger
- T: Temp increased
- O: Exposed Bone
- N: New areas of breakdown
- E: Exudate (fluid that leaks)
- E: Erythema, edema
- S: Smell
Wound Irrigation and Heat Therapy
- Irrigate wounds from top to bottom
- Heat therapy:
- Reduces muscle tension
- Treats infections
- Used for surgical wounds
- Inflamed tissue
- Arthritis
- Joint pain
Cold Therapy
- Reduces inflammation
- Reduces muscle spasm
- Produces numbness
Wound Drainage
- Serous drainage: clear, watery
- Sanguineous drainage: large number of RBC, looks like blood
- Serosanguineous drainage: mixture of serum and RBC, light pink in color
- Purulent drainage: WBC liquified, dead tissue debris, dead and alive bacteria, thick, musty, foul odor, dark yellow or green
Types of Wounds
- Penetrating wound: foreign object entering skin or mucous membrane, lodging in underlying tissue
- Contusion: blunt instrument, overlying skin intact with injury to underlying soft tissue, hematoma
- Laceration: tearing of skin and tissue with blunt or irregular instrument, tissue not aligned, loose flaps
- Abrasion: friction, rubbing or scraping epidermis, dirt and germs possible
- Eschar: necrotic, red tissue, delays wound healing, looks dry, black and leathery
- Puncture wound: blunt or sharp instrument punctures skin
- Evisceration: most serious complication of dehiscence, primary with ABD surgeries, wound completely separates
Wound Healing
- Erythema: skin redness
- Dehiscence: partial or total separation of wound, result of stress
- Wound healing by secondary intention:
- Takes longer to heal
- Left open
- Heals by itself
- Fills in and closes naturally
- Red: protect, in the proliferative stage of healing, needs gentle cleaning, moist dressings, only change when necessary
- Yellow: cleanse, indicates drainage, requires wound healing, oozing from tissue, cleaning and irrigating
- Black: debride, indicates eschar, black, brown, grey, requires removal, after debridement moves to yellow
Interventions for Skin Breakdown
- Reposition
- Wool barriers
- Antiseptic sprays
- Lotions
- Emollient
- Fluid status
- Nutritional status
- Assessments
- Pressure mattress
- Mobilization
- Maintain HOB
Factors that Affect Healing
- Age
- Medication
- Comorbidities
- Nutritional status
- Circulation
- Wound care
- Immunosuppression
Wound Closure
- Primary intention: superficial, surgical, burns
- Secondary intention: wounds that are infected
- Tertiary intension: delayed primary closure
Hemoglobin Range
- 12-18
Wound Care and Healing
- Moist heat helps soften and remove crust from wounds.
- Pressure injuries develop in soft tissue, compressed between a bony prominence and external surface.
Functions of a Dressing
- Infection prevention
- Wound healing promotion
- Protection of the wound
Signs and Symptoms of Infection
- Fever
- Redness
- Swelling
- Odor
- Malaise
- Increased pain
- Elevated pulse
- Elevated blood pressure
Wound Classification
NERDS
- N: Non-healing wound
- E: Exudative wound (leaking)
- R: Red and bleeding wound
- D: Debris from wound
- S: Smell from wound
STONEES
- S: Size is bigger
- T: Temp increased
- O: Exposed Bone
- N: New areas of breakdown
- E: Exudate (fluid that leaks)
- E: Erythema, edema
- S: Smell
Wound Irrigation and Heat Therapy
- Irrigate wounds from top to bottom
- Heat therapy:
- Reduces muscle tension
- Treats infections
- Used for surgical wounds
- Inflamed tissue
- Arthritis
- Joint pain
Cold Therapy
- Reduces inflammation
- Reduces muscle spasm
- Produces numbness
Wound Drainage
- Serous drainage: clear, watery
- Sanguineous drainage: large number of RBC, looks like blood
- Serosanguineous drainage: mixture of serum and RBC, light pink in color
- Purulent drainage: WBC liquified, dead tissue debris, dead and alive bacteria, thick, musty, foul odor, dark yellow or green
Types of Wounds
- Penetrating wound: foreign object entering skin or mucous membrane, lodging in underlying tissue
- Contusion: blunt instrument, overlying skin intact with injury to underlying soft tissue, hematoma
- Laceration: tearing of skin and tissue with blunt or irregular instrument, tissue not aligned, loose flaps
- Abrasion: friction, rubbing or scraping epidermis, dirt and germs possible
- Eschar: necrotic, red tissue, delays wound healing, looks dry, black and leathery
- Puncture wound: blunt or sharp instrument punctures skin
- Evisceration: most serious complication of dehiscence, primary with ABD surgeries, wound completely separates
Wound Healing
- Erythema: skin redness
- Dehiscence: partial or total separation of wound, result of stress
- Wound healing by secondary intention:
- Takes longer to heal
- Left open
- Heals by itself
- Fills in and closes naturally
- Red: protect, in the proliferative stage of healing, needs gentle cleaning, moist dressings, only change when necessary
- Yellow: cleanse, indicates drainage, requires wound healing, oozing from tissue, cleaning and irrigating
- Black: debride, indicates eschar, black, brown, grey, requires removal, after debridement moves to yellow
Interventions for Skin Breakdown
- Reposition
- Wool barriers
- Antiseptic sprays
- Lotions
- Emollient
- Fluid status
- Nutritional status
- Assessments
- Pressure mattress
- Mobilization
- Maintain HOB
Factors that Affect Healing
- Age
- Medication
- Comorbidities
- Nutritional status
- Circulation
- Wound care
- Immunosuppression
Wound Closure
- Primary intention: superficial, surgical, burns
- Secondary intention: wounds that are infected
- Tertiary intension: delayed primary closure
Hemoglobin Range
- 12-18
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