Wound Healing and Pressure Injury Management

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Questions and Answers

What is the primary intention of wound healing?

Healing involving the closure of a wound with skin or tissue grafts.

Healing that occurs with significant tissue loss.

Healing that requires extensive surgical intervention.

Healing that takes place under clean conditions with minimal scarring. (correct)

Which factor does NOT typically delay wound healing?

Infection at the wound site.

Excessive moisture around the wound.

Poor nutrition.

Adequate oxygenation. (correct)

Which of the following is a key element in the Braden Scale for assessing pressure injury risk?

Aging of tissue.

Mobility level. (correct)

Color of the wound.

Size of the wound.

What is the primary purpose of using negative-pressure wound therapy?

To remove drainage and speed healing Signup and view all the answers

What is a consequence of tissue necrosis in pressure injuries?

Loss of viable tissue. Signup and view all the answers

Which positioning strategy is recommended to prevent pressure ulcers?

Utilizing pillows and protectors to relieve pressure Signup and view all the answers

What role does caloric intake play in wound healing?

Increases calories and protein for healing Signup and view all the answers

Which nutrition component is essential for optimal wound healing?

Increased protein intake. Signup and view all the answers

Pressure ulcers are staged based on which criterion?

Depth of the tissue damage. Signup and view all the answers

Which of the following describes surgical debridement?

Surgical removal of necrotic tissue Signup and view all the answers

How can psychological implications affect wound care?

Patients may experience concerns about scars and odor Signup and view all the answers

What psychological impact can wounds have on patients?

Feelings of isolation and depression. Signup and view all the answers

Which debridement method involves using a sharp instrument to remove dead tissue?

Surgical debridement. Signup and view all the answers

What does the term 'secondary intention' refer to in wound healing?

Healing with extensive tissue loss and exudate Signup and view all the answers

Which wound assessment technique is used to identify organisms for effective antibiotic treatment?

Culture and sensitivity testing Signup and view all the answers

What is the significance of daily weight monitoring in wound care?

To evaluate nutritional status and recovery progress Signup and view all the answers

What appearance is characteristic of slough?

Stringy, yellow texture Signup and view all the answers

Which stage of pressure ulcer includes partial-thickness loss of dermis?

Stage 2 Signup and view all the answers

Which of the following conditions indicates that a patient may be at high risk for skin breakdown according to the Braden Scale?

Total score of 18 or less Signup and view all the answers

What is the primary goal of debridement in wound management?

To promote healing by removing necrotic tissue Signup and view all the answers

What clinical manifestation is a sign of wound infection?

Fever and increased ulcer size Signup and view all the answers

During a skin temperature assessment, what might a practitioner expect to feel in an ulceration initially?

Warm temperature Signup and view all the answers

How can tissue injury in patients be identified?

By looking for areas of skin darker than the surrounding skin Signup and view all the answers

Which of the following is NOT a potential outcome of untreated ulcers?

Increased elasticity of the skin Signup and view all the answers

Study Notes

Wound Healing

Differentiate among healing by primary, secondary, and tertiary intention.
Describe wound healing principles.

Nursing Process

Explain the nursing process in caring for individuals experiencing a wound.
Describe factors that delay healing or result in complications.

Pressure Injury Etiology

Explain the etiology and clinical manifestations of pressure injury.
Discuss using the Braden Scale to assess for pressure injury risk.

Pressure Injury Prevention

Identify measures used to prevent pressure injury development.
Explain the nursing and collaborative management of pressure injury with or without infections of the integument.

Pressure Injury Definition

A localized injury to the skin and/or underlying tissue due to pressure.

Tissue Necrosis

Cause tissue necrosis, usually over bony prominence.

Oxygenation in Pressure Injury

If tissue is under pressure against the bone, are the cells receiving oxygen?

Duration of Pressure

Length of time pressure is exerted (duration).

Tissue Tolerance Factors

Ability of tissue to tolerate externally applied pressure, influenced by age, density, collagen, and comorbidities.

Shearing Force

(Not Further Defined)

Friction

Pressure exerted on the skin when it adheres or sticks to the bed linen and the skin layers slide in the direction of body movement.
Two surfaces rubbing against each other (sheet and skin when pulling a patient up in bed).

Moisture

Excessive diaphoresis, urine, or stool.

Pressure Ulcer Staging

Pressure Ulcers are graded and staged according to the deepest area of tissue damage, from Stage 1 (minor) to Stage 4 (severe).

Slough

Appearance: Stringy, yellow texture; dead tissue, a vascular.

Eschar

Black/brown necrotic tissue; a vascular; biologic cover.

Stage 1 Pressure Ulcer

Intact skin with non-blanchable redness; possible indicators include skin temperature, tissue consistency, pain.

Stage 2 Pressure Ulcer

Partial-thickness loss of dermis; shallow open ulcer with red/pink wound bed; presents as an intact or ruptured serum-filled blister.

Stage 3 Pressure Ulcer

Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the wound color includes yellow.

Stage 4 Pressure Ulcer

Full-thickness loss can extend to muscle, bone, or supporting structures; bone, tendon, or muscle may be visible or palpable.

Unstageable Pressure Ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar; the depth and stage cannot be determined until the slough and eschar are removed.

Clinical Manifestations of Wound Infection

Signs/symptoms include leukocytosis, fever, increased ulcer size, odor, or drainage, necrotic tissue, and pain.
Untreated ulcers may lead to cellulitis, chronic infection, sepsis, and possibly death.

Braden Scale Total Score

Total Score of 23 possible; 18 or less indicates High Risk for skin breakdown.

Tissue Injury

Look for areas of skin darker than surrounding skin; may appear with red, blue, or purple hues in darker skin tones.

Skin Temperature Assessment

Assess skin temperature using your hand; an ulceration may feel warm initially, then become cooler.

Nursing Problem

Impaired Skin Integrity related to skin breakdown secondary to pressure ulcer, as evidenced by pressure sore on the sacrum.

Risk for Impaired Skin Integrity

Risk for impaired skin integrity related to immobility as evidenced by prolonged sitting.

Impaired Skin Integrity

Skin infection evidenced by open sore.

Osteomyelitis

Bone infection from bloodstream or nearby tissue.

Nutritional Deficiencies

Lack of nutrients impairs tissue healing.

Corticosteroid Drugs

Inhibit inflammatory response, impair healing.

Diabetes Mellitus

Elevated blood glucose increases infection risk.

Anemia

Reduced oxygen delivery to cells and tissues.

Wound Care

Prevent infection and promote healing.

Pressure Relief

Reduce pressure on vulnerable skin areas.

Debridement

Removal of necrotic tissue from wounds.

Primary Intention Wound Healing

Wound healing with neatly approximated edges.

Secondary Intention

Healing with extensive tissue loss and exudate.

Tertiary Intention

Delayed suturing after infection resolution.

Complications of Healing

Issues like dehiscence and hypertrophic scars.

Wound Measurements

Measured in centimeters: length, width, depth.

Negative-Pressure Wound Therapy

Suction removes drainage, speeds healing.

Culture and Sensitivity

Identifies organisms for effective antibiotic treatment.

Levine's Technique

Method for obtaining wound culture samples.

Psychological Implications

Concerns about scars and odor during care.

Caloric Intake

Increased calories and protein for healing.

Enteral Feedings

Nutritional support via feeding tubes.

Surgical Debridement

Surgical removal of necrotic tissue.

Moist Wound Healing

Keeps ulcer bed moist for better healing.

Skin Care Prevention

Avoid moisture and pressure on skin.

Positioning Devices

Use pillows and protectors to relieve pressure.

Daily Weight Monitoring

Track weight to assess nutritional status.

Healing Process

Includes regeneration and repair of tissues.

Healing Stages

Initial, granulation, maturation phases of healing.

Exudate Management

Control drainage to promote healing.

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Description

This quiz covers essential concepts related to wound healing, including the different types of healing intentions, the nursing process for wound care, and the etiology of pressure injuries. It also addresses prevention strategies and the assessment of risk using the Braden Scale. Perfect for nursing students and professionals looking to deepen their understanding of wound care.