Wound Types and Healing Intentions

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Questions and Answers

What is the definition of an abrasion?

A superficial, partial-thickness wound scraped or rubbed away.

What is an abscess?

A collection of pus and necrotic tissue resulting from an infectious process.

What is another name for a contusion?

A bruise

What is crushing?

<p>Severe trauma caused by an extreme force or weight compressing part of the body.</p> Signup and view all the answers

What is excoriation?

<p>A superficial, partial-thickness wound caused by scratching or abrasion of the skin.</p> Signup and view all the answers

Describe an incision.

<p>A clean and linear wound created by cutting into the skin and tissues with a scalpel or other sharp instrument.</p> Signup and view all the answers

What causes a laceration?

<p>A torn or jagged wound caused by blunt trauma that rips or splits the skin and underlying tissue.</p> Signup and view all the answers

What is a penetrating wound?

<p>A wound when an object pierces the skin and enters the body, creating an open wound (perforating wound if it passes completely through).</p> Signup and view all the answers

What is a puncture?

<p>A small, circular wound caused by a sharp pointed object piercing the skin.</p> Signup and view all the answers

What type of wound is a tunnel wound?

<p>A wound where the tissue is destroyed or separated from the underlying structures.</p> Signup and view all the answers

What are the characteristics of a wound that heals with primary intention?

<p>A clean, surgical incision/wound with minimal scarring that is quickly established.</p> Signup and view all the answers

What is secondary intention healing?

<p>Healing of a large, open wound from the base up and edges inward.</p> Signup and view all the answers

What describes tertiary intention healing?

<p>A wound that is left open and allowed to granulate, then surgically re-approximated.</p> Signup and view all the answers

Which of the following are considered chronic wounds? (Select all that apply)

<p>Venous stasis ulcer (A), Arterial ulcer (B), Pressure injury (C), Diabetic foot ulcer (E)</p> Signup and view all the answers

What causes arterial ulcers?

<p>Inadequate arterial blood supply (PAD).</p> Signup and view all the answers

What causes venous ulcers?

<p>Venous insufficiency.</p> Signup and view all the answers

What are the four stages of wound healing?

<p>Hemostasis, inflammatory, proliferative, and maturation.</p> Signup and view all the answers

What occurs during the hemostasis/inflammatory stage?

<p>Clotting and redness/pain.</p> Signup and view all the answers

What occurs during the proliferative stage?

<p>Granulation tissue forms, new blood vessels grow.</p> Signup and view all the answers

What happens during the maturation stage of wound healing?

<p>Collagen is remodeled and scar tissue forms.</p> Signup and view all the answers

What are the steps involved in partial-thickness wound healing?

<p>The inflammatory phase, epithelial proliferation, and maturation.</p> Signup and view all the answers

Describe the steps of full-thickness wound healing.

<p>Hemostasis, inflammatory, proliferative, and maturation phases.</p> Signup and view all the answers

Which methods are used for wound closures? (Select all that apply)

<p>Surgical glue (A), Adhesive strips (B), Surgical staples (C), Sutures (E)</p> Signup and view all the answers

Describe serous exudate.

<p>Straw-colored drainage without blood.</p> Signup and view all the answers

What is sanguineous drainage?

<p>Bloody drainage.</p> Signup and view all the answers

Define serosanguineous exudate.

<p>A mix of serous exudate and sanguineous drainage.</p> Signup and view all the answers

What type of drainage is purulent exudate?

<p>Pus, yellow, or green.</p> Signup and view all the answers

What does purosanguineous exudate look like?

<p>Blood and pus.</p> Signup and view all the answers

What is hemorrhage? How can it be a complication of wound healing?

<p>Hemorrhage is bleeding, including hematoma (internal bleeding). It is a risk factor after surgery, and it's important to check beneath the wound dressings.</p> Signup and view all the answers

What is the most common cause of infection after wound healing?

<p>Poor nutritional status.</p> Signup and view all the answers

What is dehiscence?

<p>A surgical incision that doesn't heal properly, causing a separation of the wound edges.</p> Signup and view all the answers

What is evisceration? What is the medical response to this situation?

<p>Complete separation of the wound, with protrusion of internal organs. It is a medical emergency.</p> Signup and view all the answers

What is a fistula formation?

<p>An abnormal connection between two organs, often due to an abscess, frequently at GI/GU sites.</p> Signup and view all the answers

What is the Braden Scale? What score indicates a risk for pressure ulcers?

<p>A tool for predicting pressure ulcer risk, using 6 subscales. A score less than 16 indicates a risk of developing pressure ulcers.</p> Signup and view all the answers

What does the acronym A-WOUNDD PICTUREE stand for?

<p>A: appearance, W: wound/ulcer location, O: odor, U: ulcer category, N: necrotic tissue, N: nutritional status, D: dimension, D: drainage, P: pain, I: induration, C: color, T: tunneling, U: undermining, R: redness, E: edge of skin, E: edema.</p> Signup and view all the answers

What is the four-point scale used to assess redness in dark skin?

<p>0 = no redness, 1 = mild redness, 2 = moderate redness, 3 = severe redness.</p> Signup and view all the answers

Which of the following are aseptic measures for wound care? (Select all that apply)

<p>Proper hand hygiene (A), Providing pain medication before wound care (B), Cleaning from the best looking wound to the worst (D), Sterile technique when changing dressings (E), Cleaning with sterile saline (F)</p> Signup and view all the answers

What is lavage?

<p>Irrigation of tissue with fluid.</p> Signup and view all the answers

What is debriding a wound?

<p>Removal of devitalized tissue or foreign material from a wound.</p> Signup and view all the answers

Describe sharp debriding.

<p>Use of a sharp, sterile instrument (scalpel or scissors) to remove devitalized tissue.</p> Signup and view all the answers

Which of these methods are examples of mechanical debriding? (Select all that apply)

<p>Wet-to-dry dressings (A), Hydrotherapy (whirlpool) (B), Lavage (C)</p> Signup and view all the answers

What is enzymatic debriding?

<p>Using proteolytic agents to break down necrotic tissue without affecting viable tissue.</p> Signup and view all the answers

What is autolytic debriding?

<p>Using an occlusive, moisture-retaining dressing and the body's own enzymes to break down necrotic tissue.</p> Signup and view all the answers

What is biotherapy or maggot debridement therapy?

<p>Using medical-grade larvae to dissolve dead and infected tissue.</p> Signup and view all the answers

What is the primary advantage of using a transparent film dressing?

<p>Allows air and water vapor to pass through but keeps bacteria out.</p> Signup and view all the answers

What are the benefits of gauze dressings? (Select all that apply)

<p>They can be used with hydrogels, saline, or medication. (A), They may contain antimicrobial agents or medication. (C), They are suitable for large, deep, dirty, or heavily draining wounds (D)</p> Signup and view all the answers

What is a key feature of hydrocolloid dressings?

<p>They contain water-absorbing particles that form a gel when in contact with wound fluid.</p> Signup and view all the answers

What is a benefit of hydrogels in wound care?

<p>High water content provides moisture, promotes healing, and softens dead tissue.</p> Signup and view all the answers

What is the purpose of binders and bandages in wound care?

<p>To secure dressings, reduce bleeding, and provide support for healing.</p> Signup and view all the answers

What is the general concept of applying heat and cold therapy to wounds?

<p>Heat and cold therapy can influence the body's response to injury based on factors like the injury type, treatment duration, age, skin condition, and health.</p> Signup and view all the answers

What are the common internal factors that increase the risk of pressure injury development? (Select all that apply)

<p>Dehydration (A), Immobility (C), Poor nutrition (D), Impaired sensation (E), Edema (F), Aging (G), Fever, infection (H)</p> Signup and view all the answers

Which of the following are extrinsic factors that contribute to pressure injury development? (Select all that apply)

<p>Moisture (A), Friction (C), Shearing (D), Pressure (E)</p> Signup and view all the answers

Friction damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions. AKA ______ It is the ______. This type of injury ______ classified as a pressure injury. Friction occurs when the skin ______. It can make fragile skin more vulnerable to injury, especially if the skin is also ______.

<p>SHEET BURNS, force of two surfaces moving across one another, should not be, rubs against clothing or bedding, moist</p> Signup and view all the answers

Shearing occurs when the epidermal layer slides over the dermis, causing damage to the ______. It most commonly occurs when the ______, causing shear to develop in the ______. Shear force is the ______ while the underlying muscle and bone are ______. Causing deeper fascial level damage. ______ ______.

<p>vascular bed, head of the bed is elevated and the patient slides downward, sacral area, sliding movement of skin and subcutaneous tissue, stationary, Mechanical force</p> Signup and view all the answers

What is hyperemia?

<p>After a period of tissue ischemia, if pressure is relieved and blood flow returns, the skin turns red due to vasodilation.</p> Signup and view all the answers

Explain reactive/blanching hyperemia and how it differs from non-blanching hyperemia.

<p>Reactive/blanching hyperemia means that when you press your finger on the area, it blanches (turns lighter in color) and then returns to its original color when your finger is removed. It's a sign that the blood flow is returning, and the tissue is trying to overcome being deprived of oxygen. Non-blanching means the hyperemia is advanced beyond blanching and tissue damaging is occurring.</p> Signup and view all the answers

What is tunneling?

<p>A narrow passageway extending from a wound, sometimes to other wounds, and measured in cm using a sterile, cotton-tipped applicator moistened with saline.</p> Signup and view all the answers

What is undermining?

<p>Wounds that extend in all directions due to erosion under the wound edges, resulting in a large wound with a small opening. Measured the same way as tunneling.</p> Signup and view all the answers

Explain what a Stage 1 pressure injury is and how to assess it in dark skin.

<p>A Stage 1 pressure injury is non-blanchable erythema of intact skin. Dark skin may not have visible blanching, but different color than the surrounding tissue, requiring assessment in natural or halogen light. It may also have differences in temperature or texture.</p> Signup and view all the answers

Describe the key features of a Stage II pressure injury.

<p>A Stage II pressure injury is a partial-thickness skin loss with exposed dermis. It may look like a shallow open ulcer with a red/pink wound bed. It may also present as an intact or open/ruptured serum-filled or serosanguineous-filled blister.</p> Signup and view all the answers

What is the defining characteristic of a Stage III pressure injury?

<p>A Stage III pressure injury is a full-thickness skin loss that may extend down to but not through fascia. The dermis is no longer visible. The wound may have undermining and tunneling.</p> Signup and view all the answers

What defines a Stage IV pressure injury?

<p>A Stage IV pressure injury is a full-thickness skin and tissue loss that extends to fascia, muscle, bone, or support structures such as joints. It will have visible necrosis, including slough and unstable eschar.</p> Signup and view all the answers

Describe the features of an obscured, full-thickness skin and tissue loss pressure injury.

<p>This includes damage to the skin and tissue with stable eschar (non-moveable) covering the full-thickness loss.</p> Signup and view all the answers

A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides an absorbent surface to collect wound drainage.

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

Which of the following are intrinsic (internal) factors of pressure injury development? Choose all that apply.

<p>Aging (A), Edema (B), Immobility (C), Poor nutrition (D), Impaired sensation (E), Dehydration (H), Fever, infection (J)</p> Signup and view all the answers

Which of the following are extrinsic factors of pressure injury development? Choose all that apply.

<p>Friction (B), Pressure (G), Moisture (H), Shearing (I)</p> Signup and view all the answers

Friction damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions. AKA SHEET BURNS. It is the force of two surfaces moving across one another. This type of injury should be classified as a pressure injury.

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

Flashcards

abrasion

superficial, partial-thickness wound scraped or rubbed away

abscess

collection of pus and necrotic tissue resulting from infection

contusion

bruise caused by small blood vessel rupture from trauma

crushing

severe trauma from extreme force compressing body part

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excoriation

superficial wound caused by scratching or abrasion

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incision

clean cut into the skin with a sharp tool

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laceration

torn or jagged wound from blunt trauma

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penetrating wound

wound caused by an object piercing the skin

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puncture

small, circular wound from a sharp object

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tunnel wound

tissue destroyed or separated from underlying structures

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primary intention

clean surgical incision with minimal scarring

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secondary intention

healing from base up in large open wounds

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tertiary intention

wound left open to granulate, then closed surgically

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chronic wounds

pressure injuries, diabetic foot ulcers, arterial ulcers

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arterial ulcers

caused by poor blood supply, very painful, clean borders

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venous ulcers

due to venous insufficiency, beefy red, irregular shape

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stages of wound healing

hemostasis, inflammatory, proliferative, maturation

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hemostasis/inflammatory

clotting phase with redness and pain

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proliferative

new tissue formation and granulation

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maturation

remodeling phase of the healing process

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wound closures

adhesive strips, sutures, staples, glue

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serous exudate

straw-colored fluid (no blood)

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sanguineous

drainage that is bloody

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purulent

pus that is yellow or green

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infection complication

most common post-surgery issue due to poor nutrition

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dehiscence

surgical incision that fails to heal

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evisceration

complete wound separation, protrusion, emergency

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braden scale

tool for predicting pressure ulcer risk, score below 16 indicates risk

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aseptic measures for wound care

proper hygiene and sterile techniques during dressing changes

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lavage

irrigation of tissue with fluid

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sharp debriding

removal of dead tissue with sterile instruments

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mechanical debriding

removing tissue via lavage or wet dressings

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enzymatic debriding

using agents to break down harmful tissue without harming healthy tissue

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Study Notes

Wound Types and Descriptions

  • Abrasion: Superficial wound, scraped or rubbed away.
  • Abscess: Collection of pus and dead tissue from infection.
  • Contusion (Bruise): Rupture of small blood vessels from trauma.
  • Crushing Injury: Severe trauma from extreme force or weight.
  • Excoriation: Superficial wound from scratching or abrasion.
  • Incision: Clean, linear cut with sharp instrument.
  • Laceration: Torn, jagged wound from blunt trauma.
  • Penetrating Wound: Piercing wound; object enters the body.
  • Puncture: Small, circular wound from sharp object.
  • Tunnel Wound: Tissue separation from underlying structures.

Wound Healing Intentions

  • Primary Intention: Clean incision with minimal scarring; heals quickly.
  • Secondary Intention: Large, open wound; heals from base up and in; more scarring, longer healing time.
  • Tertiary Intention: Wound left open, granulates and heals; usually from high infection risk.

Types of Chronic Wounds

  • Pressure Injury: From prolonged pressure.
  • Diabetic Foot Ulcer: From complications of diabetes.
  • Arterial Ulcer: Inadequate blood supply to the area (PAD). Clean edges, typically painful.
  • Venous Ulcer: Venous insufficiency, irregular borders, red and often painful.

Wound Healing Stages

  • Hemostasis: Blood clotting.
  • Inflammatory: Redness, pain, inflammation.
  • Proliferative: Granulation tissue and new blood vessel formation.
  • Maturation: Remodeling and scar tissue formation.

Partial-Thickness vs. Full-Thickness Wound Healing

  • Partial-Thickness: Inflammatory phase, epithelial proliferation, maturation.
  • Full-Thickness: Hemostasis, inflammatory, proliferative phases, maturation phases.

Wound Closure Methods

  • Adhesive strips
  • Sutures
  • Surgical staples
  • Surgical glue

Wound Drainage

  • Serous: Straw-colored (no blood).
  • Sanguineous: Bloody.
  • Serosanguineous: Mixture of serous and sanguineous.
  • Purulent: Pus (yellow, green).
  • Purulent Sanguineous: Blood and pus.

Wound Healing Complications

  • Hemorrhage: Bleeding (hematoma = internal bleeding).
  • Infection: Common complication from poor nutrition or unclean conditions.
  • Dehiscence: Surgical incision doesn't heal.
  • Evisceration: Total wound separation; emergency.
  • Fistula Formation: Abnormal passageway (often at GI/GU sites).

Pressure Ulcer Risk Assessment

  • Braden Scale: Tool to predict pressure ulcer risk; 6 sub-scales; < 16 at risk.
  • Wound Assessment: Includes a detailed visual review (appearance, location, odor, ulcer category, necrotic tissue, nutrition, dimension, drainage, pain, induration, color, tunneling, undermining, redness, skin edge, edema).
  • Dark Skin Scale: 0-3 grading (0= no redness, 3= severe redness).

Wound Care Aseptic Measures

  • Proper hand hygiene.
  • Sterile technique for dressing changes.
  • Cleaning with sterile saline.
  • Pain medication before treatment.
  • Clean wounds from the center outwards.
  • Prefer cleaning non-infected wounds first.

Wound Debridement

  • Sharp Debridement: Removal of devitalized tissue using sharp instruments.
  • Mechanical Debridement: Lavage, wet-to-dry dressings, and hydrotherapy.
  • Enzymatic Debridement: Use of proteolytic enzymes.
  • Autolytic Debridement: Use of occlusive dressings, body's own enzymes to break down dead tissue.
  • Biotherapy/Maggot Debridement: Use of maggots to clean wounds.

Wound Dressings

  • Transparent Film: Allows air and water vapor, prevents bacteria.
  • Gauze Dressings: Can contain medication or moisture-retaining substances.
  • Hydrocolloids: Absorbs wound fluid, protects and promotes healing.
  • Hydrogels: Jelly-like, moisture retention, softens dead tissue.

Wound Support and Immobilization

  • Binders and Bandages: Secure dressings, reduce bleeding, support.

Cold and Heat Therapy

  • Cold therapy reduces swelling and pain; should be avoided on thin skin and injured vessels/tissue and in cases like PVD or pressure injuries
  • Heat therapy used with caution.

Pressure Injury Risk Factors

  • Intrinsic (Internal): Immobility, impaired sensation, poor nutrition, dehydration, aging, fever, infections, edema
  • Extrinsic (External): Friction, pressure, shear, moisture.

Wound Assessment Terms

  • Hyperemia: Redness after tissue ischemia (blood flow restored)
  • Blanching Hyperemia: Temporary reddening that fades when pressure is released.
  • Tunneling: Narrow passageway from the wound.
  • Undermining: Erosion under the wound edges.

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