Podcast
Questions and Answers
What characterizes an open wound?
What characterizes an open wound?
Which type of wound involves complete loss of skin layers and may affect underlying structures such as muscle or bone?
Which type of wound involves complete loss of skin layers and may affect underlying structures such as muscle or bone?
What distinguishes a dirty wound from a clean wound?
What distinguishes a dirty wound from a clean wound?
Which of the following is true about chronic wounds?
Which of the following is true about chronic wounds?
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What is the primary difference between a hematoma and a bruise?
What is the primary difference between a hematoma and a bruise?
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Which type of open wound is characterized by a ragged tear in the skin?
Which type of open wound is characterized by a ragged tear in the skin?
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What defines a partial thickness wound?
What defines a partial thickness wound?
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What is a key characteristic of an avulsion wound?
What is a key characteristic of an avulsion wound?
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What is the correct method for obtaining a wound culture?
What is the correct method for obtaining a wound culture?
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Which characteristic is not associated with superficial (first-degree) burns?
Which characteristic is not associated with superficial (first-degree) burns?
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What is the primary treatment for a stage 2 pressure ulcer?
What is the primary treatment for a stage 2 pressure ulcer?
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How often should a patient be repositioned to prevent pressure ulcers?
How often should a patient be repositioned to prevent pressure ulcers?
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Which of the following is true about the Braden Scale?
Which of the following is true about the Braden Scale?
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Which type of burn extends through the skin into underlying muscle and bone?
Which type of burn extends through the skin into underlying muscle and bone?
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What aspect is primarily evaluated in a patient with an arterial ulcer?
What aspect is primarily evaluated in a patient with an arterial ulcer?
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Which stage of pressure ulcer involves full thickness tissue loss with exposed bone, muscle, or tendon?
Which stage of pressure ulcer involves full thickness tissue loss with exposed bone, muscle, or tendon?
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What is the primary role of replacement tissue in wound healing?
What is the primary role of replacement tissue in wound healing?
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Which of the following factors can impair wound healing due to poor blood flow?
Which of the following factors can impair wound healing due to poor blood flow?
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During which phase of wound healing does fibroblast activity and collagen production primarily occur?
During which phase of wound healing does fibroblast activity and collagen production primarily occur?
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What type of wound healing occurs when a wound cannot be closed surgically?
What type of wound healing occurs when a wound cannot be closed surgically?
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What does a red color indicate in a wound's healing status?
What does a red color indicate in a wound's healing status?
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Which of the following medications is known to delay wound healing by inhibiting inflammatory responses?
Which of the following medications is known to delay wound healing by inhibiting inflammatory responses?
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Sanguineous drainage is characterized by which of the following features?
Sanguineous drainage is characterized by which of the following features?
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Which sign is NOT considered a symptom of hypovolemic shock?
Which sign is NOT considered a symptom of hypovolemic shock?
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What indicates a potential infection in a wound?
What indicates a potential infection in a wound?
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What does dehiscence refer to in the context of surgical wounds?
What does dehiscence refer to in the context of surgical wounds?
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Which intervention could help improve a patient's wound healing related to nutrition?
Which intervention could help improve a patient's wound healing related to nutrition?
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What does purulent drainage typically indicate about a wound?
What does purulent drainage typically indicate about a wound?
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In which situation might terciary intention for wound healing be applied?
In which situation might terciary intention for wound healing be applied?
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Which characteristic of wound drainage signifies the inflammatory phase is resolving?
Which characteristic of wound drainage signifies the inflammatory phase is resolving?
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What describes the tissue that forms during the second step of wound healing?
What describes the tissue that forms during the second step of wound healing?
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Which type of drainage is a mixture of clear fluid and blood?
Which type of drainage is a mixture of clear fluid and blood?
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What does the term 'dehisced' refer to in wound healing?
What does the term 'dehisced' refer to in wound healing?
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Which stage of pressure ulcer is characterized by non-blanchable redness?
Which stage of pressure ulcer is characterized by non-blanchable redness?
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What type of drain is used to remove fluid through suction?
What type of drain is used to remove fluid through suction?
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Study Notes
Wound Classification and Healing
- Open Wounds: A break in the skin, exposing underlying tissues.
- Closed Wounds: Skin remains intact, underlying tissues damaged (e.g., contusion, hematoma).
- Partial-Thickness Wounds: Affect only the epidermis and superficial dermis layers.
- Full-Thickness Wounds: Affect all skin layers, possible extended damage to underlying tissues.
- Clean Wounds: Surgical incisions with minimal damage and low infection risk.
- Dirty Wounds: Significant tissue damage and contamination, higher infection risk.
- Acute Wounds: Recent onset, heal within the expected timeframe.
- Chronic Wounds: Fail to heal in a timely manner.
Hematoma vs. Bruise
- Hematoma: Localized collection of blood under the skin, significant bleeding and swelling.
- Bruise: Smaller area of discoloration, less swelling and blood accumulation.
Open Wound Types
- Laceration: Ragged tear in the skin from blunt force.
- Abrasion: Superficial scrape or rub of the skin's top layers.
- Puncture: Small hole caused by a sharp object piercing the skin.
- Avulsion: Skin and underlying tissue torn away or pulled off.
- Ulceration: Open sore or lesion with tissue breakdown.
Tissue Replacement vs. Original Tissue
- Replacement tissue (fibrous connective) differs functionally from the original tissue. It offers structural support, not the original tissue's specific functions.
Chronic Wound Causes
- Diabetes: Impaired healing due to high blood sugar.
- Poor Circulation: Reduced blood flow slows healing.
- Immobility: Constant pressure creates pressure ulcers.
Wound Healing Phases
- Inflammatory Stage (0-3 days): Immune response, blood vessel dilation, debris/bacteria removal.
- Proliferation Stage (3 days - 3 weeks): New tissue formation, collagen production, new blood vessel growth, epithelial resurfacing.Granulation tissue- red, bumpy tissue forming during wound healing second step of wound healing
- Maturation Stage (3 weeks - 2 years): Wound closure, collagen reorganization, scar contraction and maturation, decreased blood supply.
Wound Healing Types
- Primary Intention: Wound edges approximated (e.g., sutured surgical incision), rapid healing, minimal scarring.Staples/skin clips - devices used to close surgical incisions Sutures - threads used to close surgical incisions
- Secondary Intention: Tissue loss, wound left open to heal from the bottom up, more extensive scarring.
- Tertiary Intention: Wound left open initially, allowed to granulate and clear infection before closing.
Wound Color Significance
- Red: Active healing, granulation tissue present.
- Yellow/Tan: Slough (soft, moist, necrotic tissue), needs debridement.
- Black/Brown: Necrotic tissue (eschar - thick, leathery, necrotic tissue), requires debridement.
- Green: Possible infection (Pseudomonas).
- Red/Angry: Erythema, infection spreading (cellulitis).
- Foul Odor: Potential necrotic tissue or anaerobic bacteria.
Factors Affecting Wound Healing & Interventions
- Nutrition: Balanced diet essential for cellular healing processes. Consult a dietitian.
- Chronic Illnesses: Manage underlying conditions to optimise healing. Education on disease management.
- Age: Adjusting care for slower healing in older adults.
- Smoking: Discourage smoking due to impaired healing.
- Immobility: Reposition patient frequently to prevent pressure ulcers.
Medications Affecting Wound Healing
- Corticosteroids: Inhibit healing, delay inflammation and cell migration.
- Immunosuppressants: Impair immune system functioning for wound healing.
- Anticoagulants/Antiplatelets: Increase bleeding, disrupt clot formation.
Wound Drainage Types
- Sanguineous: Bright red blood drainage, immediate after injury/surgery.
- Serosanguineous: Pinkish drainage, blood diluted with serous fluid. Days after injury/surgery.
- Serous: Clear, pale yellow fluid, inflammatory phase resolving.
- Purulent: Thick, opaque, contains white blood cells & bacteria, indicates infection.
Hypovolemic Shock S/S
- Tachycardia (rapid heart rate)
- Hypotension (low blood pressure)
- Tachypnea (rapid breathing)
- Cool, pale, mottled skin
- Delayed capillary refill
- Decreased urine output
- Lethargy/irritability
- Dry mucous membranes
Surgical Site Hemorrhage Assessment
- Frequent dressing checks for bleeding.
- Monitor drainage from surgical drains.Penrose drain - rubber drain used to remove fluid from wounds Jackson Pratt drain - closed suction drain to remove fluid.
- Observe for blood pooling/drainage around dressings.
- Vital sign monitoring for hypovolemia.
- Assess for hypovolemic shock symptoms.
- Palpate surgical site for swelling or firmness (hematoma).
Wound Infection S/S
- Redness, warmth around wound.
- Swelling, edema.
- Increased pain, tenderness.
- Foul odor.
- Thick, purulent (yellow, green, brown) drainage.
- Fever.
- Elevated white blood cell count.
Dehiscence vs. Evisceration
- Dehiscence: Partial separation of a surgical wound.
- Evisceration: Protrusion of internal organs through the wound dehiscence.Well approximated - wound edges neatly aligned Dehisced - wound has opened/separated
- Occurrence: 5-12 days post-surgery.
- Action: Place in relieving position, cover with sterile saline dressing, notify surgeon immediately.
Wound Culture Procedure
- Clean wound with saline.
- Collect sample with sterile swab/needle from wound bed.
- Place in sterile container, send to lab.
Burn Types
- Superficial (First-degree): Epidermis only, redness, pain, no blisters.
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Partial-Thickness:
- Superficial: Epidermis and upper dermis, blisters.
- Deep: Deeper into dermis, white/waxy appearance.
- Full-Thickness (Third-degree): Entire skin thickness, leathery/charred.
- Fourth-degree: Extends beyond skin to underlying muscle and bone.
Pressure Ulcer Stages & Treatment
- Stage 1: Non-blanchable redness of intact skin. Relieve pressure, protect area.
- Stage 2: Partial-thickness skin loss (epidermis/dermis). Moisture-retentive dressings, pressure relief.
- Stage 3: Full-thickness tissue loss through dermis. Debridement, moisture dressings, pressure redistribution.
- Stage 4: Full-thickness skin and tissue loss, bone/muscle/tendon exposed. Surgical debridement, negative pressure therapy, pressure relief.
Pressure Ulcer Prevention
- Frequent repositioning, pressure relief.
Braden Scale
- Tool for assessing pressure ulcer risk. Evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Arterial vs. Venous Ulcers
- Arterial: Poor arterial blood flow, punched-out appearance, pale wound bed. Treated with revascularization.
- Venous: Venous insufficiency, irregular edges, heavy drainage. Treated with compression therapy and addressing underlying venous disease.
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Description
Test your knowledge on different types of wounds and their healing processes. This quiz covers classifications of open and closed wounds, types of hematomas versus bruises, and the characteristics of acute and chronic wounds. Challenge yourself and see how well you understand wound management!
