Wound Care and Management

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Questions and Answers

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?

  • 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?

  • 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?

<p>To reduce muscle tension and promote relaxation (A)</p> Signup and view all the answers

What type of wound is characterized by a foreign object entering the skin or mucous membrane?

<p>Puncture wound (A)</p> Signup and view all the answers

What is the primary characteristic of eschar?

<p>Dry, black, and leathery tissue (C)</p> Signup and view all the answers

What is the purpose of irrigating wounds from top to bottom?

<p>To clean the wound and remove debris (D)</p> Signup and view all the answers

What is the main difference between serous and purulent drainage?

<p>Color and consistency (D)</p> Signup and view all the answers

What is the most serious complication of dehiscence?

<p>Evisceration (D)</p> Signup and view all the answers

What does yellow indicate in wound healing?

<p>Drainage (A)</p> Signup and view all the answers

What is the main purpose of repositioning in wound care?

<p>To reduce pressure on the wound (C)</p> Signup and view all the answers

What is the range of hemoglobin levels in a healthy individual?

<p>12-18 (B)</p> Signup and view all the answers

What is the primary intention of wound healing?

<p>Surgical closure of the wound (D)</p> Signup and view all the answers

What is the term for the partial or total separation of a wound?

<p>Dehiscence (A)</p> Signup and view all the answers

Moist heat helps remove debris from a wound.

<p>True (A)</p> Signup and view all the answers

Pressure injury develops in bone tissue.

<p>False (B)</p> Signup and view all the answers

Dehiscence is the most serious complication of evisceration.

<p>False (B)</p> Signup and view all the answers

A wound dressing prevents infection.

<p>True (A)</p> Signup and view all the answers

Fever is not a sign of infection in a wound.

<p>False (B)</p> Signup and view all the answers

Wound healing by secondary intention takes less time to heal.

<p>False (B)</p> Signup and view all the answers

NERDS is an acronym used to describe a certain type of wound.

<p>True (A)</p> Signup and view all the answers

Red dressing is used to protect the wound.

<p>True (A)</p> Signup and view all the answers

Cold therapy is used to reduce muscle tension.

<p>True (A)</p> Signup and view all the answers

Yellow dressing indicates the need for wound healing.

<p>False (B)</p> Signup and view all the answers

Black dressing indicates eschar and requires removal.

<p>True (A)</p> Signup and view all the answers

Serosanguineous drainage is a mixture of serum and white blood cells.

<p>False (B)</p> Signup and view all the answers

The normal range of hemoglobin level is between 10-16.

<p>False (B)</p> Signup and view all the answers

A penetrating wound is caused by a blunt instrument.

<p>False (B)</p> Signup and view all the answers

Moist heat helps soften and remove ______ from a wound.

<p>crust</p> Signup and view all the answers

Pressure injury develops in ______ tissue.

<p>soft</p> Signup and view all the answers

A function of a dressing is to prevent ______.

<p>infection</p> Signup and view all the answers

Signs and symptoms of infection include ______.

<p>fever</p> Signup and view all the answers

NERDS is an acronym used to describe a ______ wound.

<p>non-healing</p> Signup and view all the answers

STONEES is an acronym used to describe ______ in wound care.

<p>signs</p> Signup and view all the answers

Heat therapy reduces ______ tension.

<p>muscle</p> Signup and view all the answers

Purulent drainage is characterized by a ______ odor.

<p>foul</p> Signup and view all the answers

Evisceration is a complication of _______________

<p>dehiscence</p> Signup and view all the answers

Wound healing by _______________ intention takes longer to heal

<p>secondary</p> Signup and view all the answers

Skin redness is also known as _______________

<p>erythema</p> Signup and view all the answers

Interventions for skin breakdown include _______________ and reposition

<p>wool barriers</p> Signup and view all the answers

Factors that affect healing include _______________ and nutritional status

<p>circulation</p> Signup and view all the answers

The normal range of hemoglobin levels is between _______________

<p>12-18</p> Signup and view all the answers

What helps soften and remove crust in wound care?

<p>Moist heat (A)</p> Signup and view all the answers

What type of wound develops in soft tissue?

<p>Pressure injury (D)</p> Signup and view all the answers

What is a function of a dressing in wound care?

<p>Protecting the wound (A)</p> Signup and view all the answers

What are signs and symptoms of infection in a wound?

<p>All of the above (D)</p> Signup and view all the answers

What does NERDS stand for in wound care?

<p>Non-healing, Exudative, Red, Debris, Smell (C)</p> Signup and view all the answers

What is the purpose of heat therapy in wound care?

<p>Reducing muscle tension (D)</p> Signup and view all the answers

What is the characteristic of purulent drainage?

<p>Thick and foul-smelling (C)</p> Signup and view all the answers

What is eschar?

<p>Dead, necrotic tissue (C)</p> Signup and view all the answers

What is the result of dehiscence?

<p>Wound completely separates (C)</p> Signup and view all the answers

What is the purpose of yellow dressings in wound healing?

<p>To indicate drainage (A)</p> Signup and view all the answers

What is a factor that affects wound healing?

<p>All of the above (D)</p> Signup and view all the answers

What is the term for wound healing that occurs naturally, without surgical intervention?

<p>Secondary intention (C)</p> Signup and view all the answers

What is the term for skin redness?

<p>Erythema (A)</p> Signup and view all the answers

What is an intervention for skin breakdown?

<p>All of the above (D)</p> Signup and view all the answers

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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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