Stages of Wound Healing and Pressure Ulcer Treatment, Exams of Nursing

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Wound Care stages of healing 2024 What are the four stages of wound healing?\ CORRECT ANSWER IS Homeostasis - vessels constrict, platelets aggregate, bleeding Inflammation - stimulation of capillary growth Proliferation - granulation tissue is formed Remodeling - strengthening the wound True or False: The phases of wound healing can be disrupted.\ CORRECT ANSWER IS True True or False: Red beefy tissue is helping the healing process.\ CORRECT ANSWER IS True, it's called red granulation tissue What are building blocks of wound healing\ CORRECT ANSWER IS fibroblasts, collagen and glycoproteins, epidermal cells True or False: The area where a wound as healed will only have 60% of the strength that it had before the would occurred\ CORRECT ANSWER IS False, it will be 80% What is important to consider when treating wounds?\ CORRECT ANSWER IS To support the phases of wound healing and to make sure not to disrupt them Black or yellow sloughing tissue indicates what?\ CORRECT ANSWER IS Dead tissue What is white tissue that is non-viable and it is caused by exposure to moisture?\ CORRECT ANSWER IS Maceration True or False: The maturation phase of wound healing could last as long as one year or more.\ CORRECT ANSWER IS True True or False: It is unimportant to investigate the history of the wound and find the underlying cause.\ CORRECT ANSWER IS False, it is very important to get a complete health history and find the cause of the wound to treat it properly. What are some factors that would impair wound healing?\ CORRECT ANSWER IS Issues with tissue perfusion, oxygenation, diabetes, BP, anemia, low serum albumin, decreased food intake, malnourished and body weight What are the signs of an infection in a wound?\ CORRECT ANSWER IS Reddened peri-wound tissue, changes in V/S, high white count How do corticosteroids impair healing?\ CORRECT ANSWER IS They suppress the immune system and slow the process of would healing When you first notice a Stage I pressure ulcer, what should you do?\ CORRECT ANSWER IS RELIEVE PRESSURE! Remove moisture, reduce friction and shear True or False: When a pressure ulcer is staged at diagnosis, it remains that same stage until it is healed.\ CORRECT ANSWER IS True What is a Stage I Ulcer?\ CORRECT ANSWER IS Non-blanchable erythema of intact skin, can be firm/boggy, or colder/warmer than surrounding skin What is a Stage II Ulcer?\ CORRECT ANSWER IS Partial thickness skin loss involving epidermis and/or dermis What is a Stage III Ulcer?\ CORRECT ANSWER IS Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down, but not through, the underlying fascia What is a Stage IV Ulcer?\ CORRECT ANSWER IS Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. Eschar, yellow sloughing What is undermining?\ CORRECT ANSWER IS Space hidden under the edges of a wound, test this by using sterile gloves and a sterile Q-tip In Stage 3 and 4 What is tunneling of a wound?\ CORRECT ANSWER IS A tunnel in a wound In stage 3 and 4 How is bioengineered skin used to heal a pressure ulcer?\ CORRECT ANSWER IS It is sutured onto the wound and acts like a skin graft and sometimes it is only hope for healing the wound When is a pressure ulcer unstageable?\ CORRECT ANSWER IS When the ulcer is covered with slough or eschar ad it needs to be removed before staging can occur. What might a deep tissue injury look like?\ CORRECT ANSWER IS purple/maroon localized area of intact skin or blood filled blister What does T.I.M.E. principles of Wound Bed Preparation stand for?\ CORRECT ANSWER IS T - tissue I - Inflammation M - Moisture E - Edges DO NOT USE FOR DRAINING WOUNDS Autolytic debridement Used for dry wounds What is the purpose gauze?\ CORRECT ANSWER IS Fills wounds, absorbs. Used on mostly surgical wounds and not chronic wounds Not the number 1 choice What is impregnated gauze used for?\ CORRECT ANSWER IS Can be used for tunneling/undermining can be non-adherant Xeroform True or False: Enzymes work in a dry environment.\ CORRECT ANSWER IS False! You would need to add moisture. What are the secondary signs of infection?\ CORRECT ANSWER IS Delayed healing, change in color/wound bed, friable granulation tissue, absent/abnormal granulation tissue, increase/abnormal What is the purpose of an antimicrobial dressing?\ CORRECT ANSWER IS The healing process has slowed/stop There may be an infection forming Bacteria What is action of the silver antimicrobial dressing?\ CORRECT ANSWER IS Creates a gel as it absorbs wound drainage wound drainage activates silver and antimicrobial action begins used on burns and select wounds What are Iodine dressings used for?\ CORRECT ANSWER IS Reduces microbial burden including MRSA, no harmful effects on cells Absorbs slough, debris and exudate to clean the wound bed CONTRAINDICATED in patients with thyroid disease What is the purpose of the Negative pressure wound therapy vacuum assisted closure?\ CORRECT ANSWER IS Helps to contract the wound, sucks out the dead tissue and exudate, helps with migration of the edges of the wound Advanced therapy What are the vacuum assisted closures used for?\ CORRECT ANSWER IS Chronic open wounds dehisced surgical wounds stage III and IV pressure ulcers Vacuum assisted closures are contraindicated with...\ CORRECT ANSWER IS Cancer in the wound or surrounding tissues Fistulas Necrotic Tissue Untreated osteomyelitis How often does a vacuum assisted closure need to be changed?\ CORRECT ANSWER IS about three times a day True or False: If vacuum is stopped for 2 or more hours, the dressing needs to be changed.\ CORRECT ANSWER IS True True or False: Dressings do not replace the basic principles of wound healing\ CORRECT ANSWER IS TRUE, you need to investigate the cause and correct causative factors What is Hemosiderin ?\ CORRECT ANSWER IS staining due to the break down of red blood cells, usually seen between the ankle and the knee Seen in patients with venous insufficiency What are the common characteristics of venous ulcers?\ CORRECT ANSWER IS Irregular edges, may be partial or full thickness usually in gaiter area/medical malleolus beefy red/yellow slough large amount of exudate EDEMA Periwound skin will be macerated, crusted and scaling What are the common characteristics of arterial ulcers?\ CORRECT ANSWER IS well defined edges distal aspect of extremity, pressure points of foot minimal exudate faint halo erythema around periwound skin