Wound Care Flashcards

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Questions and Answers

What is primary intention in wound healing?

Wounds that are contaminated

Wounds with extensive tissue loss

Wounds that need delayed closure

Wounds with well approximated edges (correct)

What characterizes secondary intention in wound healing?

Wounds healed with minimal scarring

Large, open wounds requiring more tissue replacement (correct)

Edges closely approximated

Wounds healed with stitches

What is tertiary intention?

Delayed primary closure of wounds.

What is a stage I pressure ulcer?

Intact skin with nonblanchable redness Signup and view all the answers

Describe stage II pressure ulcer.

Partial thickness loss of dermis presenting as a shallow, open ulcer. Signup and view all the answers

What defines a stage III pressure ulcer?

Full-thickness tissue loss with subcutaneous fat visible. Signup and view all the answers

What is a stage IV pressure ulcer?

Full-thickness tissue loss with exposed bone, tendon, or muscle. Signup and view all the answers

To clean wounds with approximated edges, you should clean from _ to _.

top, bottom Signup and view all the answers

For unapproximated edges, clean in full or half circles, starting from the center and moving toward the ___ .

outside Signup and view all the answers

What is an incision?

A cut made with a sharp instrument where the edges are aligned. Signup and view all the answers

Define contusion.

A bruise caused by a blunt instrument with intact skin. Signup and view all the answers

What is an abrasion?

A wound caused by friction that scrapes the epidermal layer. Signup and view all the answers

What defines a laceration?

Tearing of skin and tissue with blunt or irregular instrument. Signup and view all the answers

What is a puncture?

A wound made by a blunt or sharp instrument penetrating the skin. Signup and view all the answers

What are pressure ulcers?

Wounds caused by compromised circulation due to pressure. Signup and view all the answers

What is shearing in the context of wound care?

When one layer of tissue slides over another layer. Signup and view all the answers

What does dehiscence mean?

Separation of the wound layers. Signup and view all the answers

Define avulsion.

A deep tearing that damages tissue and may expose underlying structures. Signup and view all the answers

What is gauze used for?

To absorb blood or drainage. Signup and view all the answers

What are Montgomery straps?

Strips of tape with eyelets to secure gauze dressings. Signup and view all the answers

What is the purpose of transparent dressings?

To protect intravenous insertion sites. Signup and view all the answers

Describe the function of hydrocolloid dressings.

They keep a wound moist and limit oxygen exchange. Signup and view all the answers

Study Notes

Wound Healing Intentions

Primary intention: Wounds with edges closely approximated, minimal tissue loss (e.g., surgical incision).
Secondary intention: Open wounds with non-approximated edges, such as burns or trauma, require tissue replacement and take longer to heal with more scar tissue.
Tertiary intention: Wounds left open initially to resolve infection or drainage and later closed.

Pressure Ulcers Stages

Stage I: Intact skin with non-blanchable redness over bony prominences; may show changes in skin temperature or texture.
Stage II: Partial thickness loss of dermis, presenting as a shallow, open ulcer or blister.
Stage III: Full-thickness tissue loss with visible subcutaneous fat, potential undermining and tunneling.
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle, often with slough or eschar present.

Wound Cleaning Techniques

Cleaning wounds with approximated edges: Utilize sterile techniques, moisten gauze with cleansing agent, clean from top to bottom, working outward parallel to the incision.
Cleaning wounds with unapproximated edges: Use sterile gauze or swab in circular motions from the center to the outside, extending cleaning beyond the wound margins.

Types of Wounds

Incision: A cut with aligned edges, created by a sharp instrument.
Contusion: Blunt force injury, skin intact, underlying tissue may bruise.
Abrasion: Skin scraped off due to friction.
Laceration: Tearing of skin, creating irregular edges and loose tissue.
Puncture: Abrupt breach of skin by a sharp instrument, can be intentional or accidental.

Additional Concepts

Pressure ulcers: Result from compromised circulation due to prolonged pressure or friction.
Shearing: Tissue layers sliding over each other, often caused by improper lifting techniques.
Dehiscence: Partial or total separation of wound layers, common in patients who are obese or malnourished.
Avulsion: Deep tearing from its anatomical position, potentially exposing bones or blood vessels.

Dressings and Supports

Gauze: Used for absorption of blood or drainage.
Montgomery straps: Tape strips with eyelets for securing dressings that need frequent changes.
Transparent dressings: Such as OpSite, primarily protect IV insertion sites.
Hydrocolloid dressings: Examples include Duoderm and Tegasorb, promote a moist wound environment and provide cushioning.

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Description

This quiz covers essential concepts in wound healing, focusing on primary and secondary intention. Understand the differences between well approximated wounds and those that require longer healing times. Perfect for students in healthcare or nursing programs.