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120 Cards in this Set
- Front
- Back
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The nurse is documenting data about the healing wound on a clients lower leg. the predominant exudate in the wound is watery inconsistency and light red and color. the nurse should document which of the following types of wound drainage - Serosanguineous - Serous - Sanguineous - Purulent |
Serosanguineous |
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A nurse is teaching a pressure injury over clients right heel area. the pressure injury has no Eschar or slough and no expose muscle or bones. the nurse should identify that this pressure injury is classified as which of the following - stage 3 - Unstageable - stage 4 - deep tissue |
Stage 3 |
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A nurse is documenting data about a deep necrotic wound on a client’s left buttock. the nurse observes a yellow ish tan soft string area of the necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document. - Keloid - Slough - Granulation - Eschar |
Slough |
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A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis |
Alginate |
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A nurse is selecting dressings for a client with a full thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care which of the following types of dressings should the nurse select to help minimize the pain of dressing changes - Wet to dry - Abdominal pads (ABD) - Dry gauze - Hydrogel |
Hydrogel |
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A nurse is caring for a patient who has developed a stage one pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the clients pressure injury - Barrier creams - Antifungal ointment - Chemical debridement agent - antibiotic agent |
Barrier cream |
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A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care - leave non bleeding wounds open to the air - administer corticosteroid medication - initiate mechanical Debridement - apply oxygen at 2 L/min via nasal cannula |
Apply oxygen at 2 L/min via nasal cannula |
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A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medication is known to delay wound healing - tricyclic antidepressants - Corticosteroids - anti-cholinergics - beta blockers |
Corticosteroids |
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A nurse is caring for a client who has a stage four sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical department that the nurse should expect the client to receive - Planning a transparent dressing over the pressure injury - applying hydrocolloids to the wound bed - pulsating lavage - using a topical enzyme solution in the wound bed |
Pulsating lavage |
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A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis - Transparent - Hydrogel - Alginate - Dry gauze |
Alginate |
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What are the types of wounds |
Open Closed Partial thickness Full thickness |
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What is an open wound |
Wound goes through the skin, break in the skin |
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What is a closed wound |
Without a break in the skin |
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What are the types of wounds |
Open Closed Partial thickness Full thickness |
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What is an open wound |
Wound goes through the skin, break in the skin |
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What is a closed wound |
Without a break in the skin |
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Name some types of closed wounds |
Hematoma Contusion Sprain |
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What are the types of wounds |
Open Closed Partial thickness Full thickness |
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What is an open wound |
Wound goes through the skin, break in the skin |
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What is a closed wound |
Without a break in the skin |
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Name some types of closed wounds |
Hematoma Contusion Sprain |
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What is a partial thickness wound |
Superficial wound that heals more quickly |
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What are the types of wounds |
Open Closed Partial thickness Full thickness |
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What is a closed wound |
Without a break in the skin |
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Why do partial thickness wounds heal quickly |
They are closer to the surface and new skin cells are quickly produced by the epithelial cell that remain in the dermal layer of the skin |
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What are the types of wounds |
Open Closed Partial thickness Full thickness |
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What is an open wound |
Wound goes through the skin, break in the skin |
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What is a closed wound |
Without a break in the skin |
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Name some types of closed wounds |
Hematoma Contusion Sprain |
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What is a partial thickness wound |
Superficial wound that heals more quickly |
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Why do partial thickness wounds heal quickly |
They are closer to the surface and new skin cells are quickly produced by the epithelial cell that remain in the dermal layer of the skin |
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Which type of wound has no dermal layer left, except at the wound margin |
Full thickness wound |
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How does a full thickness wound heal |
It’s healed by removing all the dead necrotic tissue so granulation tissue can fill in |
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Does replacement tissue have the same functional characteristics as tissue lost |
No, generally the fibrous connective tissue is not the same as the original |
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Does replacement tissue have the same functional characteristics as tissue lost |
No, generally the fibrous connective tissue is not the same as the original |
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What are the two primary methods of wound healing |
Replacement of cells Regeneration |
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Does replacement tissue have the same functional characteristics as tissue lost |
No, generally the fibrous connective tissue is not the same as the original |
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What are the two primary methods of wound healing |
Replacement of cells Regeneration |
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What is necrosis |
Tissue death |
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Explain replacement and regeneration of tissues |
Replacement is tissue lost and when formed it does not have the same characteristics Regeneration is when the new tissue cells forms and look similar to the ones lost |
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Explain replacement and regeneration of tissues |
Replacement is tissue lost and when formed it does not have the same characteristics Regeneration is when the new tissue cells forms and look similar to the ones lost |
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Which tissues are generally unable to regenerate |
Heart muscle and the central spinal nerve cells |
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Explain replacement and regeneration of tissues |
Replacement is tissue lost and when formed it does not have the same characteristics Regeneration is when the new tissue cells forms and look similar to the ones lost |
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Which tissues are generally unable to regenerate |
Heart muscle and the central spinal nerve cells |
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What are the three phases of wound healing |
Inflammatory phase Proliferation or reconstruction phase Maturation or remodeling phase |
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What is inflammation |
A localized protective response brought on by injury or destruction of tissues |
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What is inflammation |
A localized protective response brought on by injury or destruction of tissues |
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When does the inflammation stage begin |
Immediately after injury |
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How long does the inflammatory phase last |
3-4 days |
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What is Hemostasis |
Blood clotting or vessel compression |
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What is Hemostasis |
Blood clotting or vessel compression |
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What are the Clinical signs of inflammation |
Swelling (edema), heat (increase in temperature), pain, loss of function, redness (erythema) |
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When does the proliferation stage begin |
On the 3rd or 4th day |
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When does the proliferation stage begin |
On the 3rd or 4th day |
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How long does the proliferation stage last |
2-3 weeks |
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When does the proliferation stage begin |
On the 3rd or 4th day |
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How long does the proliferation stage last |
2-3 weeks |
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What is the main ingredient of scar tissue |
Collagen |
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When does the proliferation stage begin |
On the 3rd or 4th day |
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How long does the proliferation stage last |
2-3 weeks |
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What is the main ingredient of scar tissue |
Collagen |
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What does the skin look like in the proliferation stage |
Skin tissue is deep pink |
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When does maturation start |
3 weeks after the injury |
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When does maturation start |
3 weeks after the injury |
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What are the clinical signs of the maturation phase |
Scar tissue slowly thins and becomes paler Collagen is lysed (broken down |
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When does maturation start |
3 weeks after the injury |
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What are the clinical signs of the maturation phase |
Scar tissue slowly thins and becomes paler Collagen is lysed (broken down |
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What are the types of wound healing |
1st intention 2nd intention 3rd intention |
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When does maturation start |
3 weeks after the injury |
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What are the clinical signs of the maturation phase |
Scar tissue slowly thins and becomes paler Collagen is lysed (broken down |
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What are the types of wound healing |
1st intention 2nd intention 3rd intention |
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Collagen overgrowth is known as ? |
Keloid |
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When does maturation start |
3 weeks after the injury |
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What are the clinical signs of the maturation phase |
Scar tissue slowly thins and becomes paler Collagen is lysed (broken down |
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What are the types of wound healing |
1st intention 2nd intention 3rd intention |
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Collagen overgrowth is known as ? |
Keloid |
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What is the 1st intention wound healing |
Wound with a little tissue loss - surgical incisions |
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When does maturation start |
3 weeks after the injury |
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What are the clinical signs of the maturation phase |
Scar tissue slowly thins and becomes paler Collagen is lysed (broken down |
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What are the types of wound healing |
1st intention 2nd intention 3rd intention |
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Collagen overgrowth is known as ? |
Keloid |
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What is the 1st intention wound healing |
Wound with a little tissue loss - surgical incisions |
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Which type of wound healing is approximated and what does that mean |
1st intention approximated Means that the edges of the wound are close together |
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When does maturation start |
3 weeks after the injury |
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What are the clinical signs of the maturation phase |
Scar tissue slowly thins and becomes paler Collagen is lysed (broken down |
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What are the types of wound healing |
1st intention 2nd intention 3rd intention |
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Collagen overgrowth is known as ? |
Keloid |
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What is the 1st intention wound healing |
Wound with a little tissue loss - surgical incisions |
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Which type of wound healing is approximated and what does that mean |
1st intention approximated Means that the edges of the wound are close together |
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What is 2nd intention wound healing |
Wound that is left open and filled with scar tissue |
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When does maturation start |
3 weeks after the injury |
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What are the clinical signs of the maturation phase |
Scar tissue slowly thins and becomes paler Collagen is lysed (broken down |
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What are the types of wound healing |
1st intention 2nd intention 3rd intention |
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Collagen overgrowth is known as ? |
Keloid |
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What is the 1st intention wound healing |
Wound with a little tissue loss - surgical incisions |
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Which type of wound healing is approximated and what does that mean |
1st intention approximated Means that the edges of the wound are close together |
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What is 2nd intention wound healing |
Wound that is left open and filled with scar tissue |
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What are the clinical signs of 2nd intention wound healing |
Tissue loss Edges do not approximate to Wound is left open |
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When does maturation start |
3 weeks after the injury |
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What are the clinical signs of the maturation phase |
Scar tissue slowly thins and becomes paler Collagen is lysed (broken down |
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What are the types of wound healing |
1st intention 2nd intention 3rd intention |
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Collagen overgrowth is known as ? |
Keloid |
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What is the 1st intention wound healing |
Wound with a little tissue loss - surgical incisions |
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Which type of wound healing is approximated and what does that mean |
1st intention approximated Means that the edges of the wound are close together |
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What is 2nd intention wound healing |
Wound that is left open and filled with scar tissue |
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What are the clinical signs of 2nd intention wound healing |
Tissue loss Edges do not approximate to Wound is left open |
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What are the clinical signs of 3rd intention wound healing |
Delayed suturing of wound |
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Factors that affect wound healing |
Age Nutrition Lifestyle Medication Infection Chronic Illness |
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Factors that affect wound healing |
Age Nutrition Lifestyle Medication Infection Chronic Illness |
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What kind of medication can interfere with wound healing |
Steroids and other anti-inflammatory medications Heparin |
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How does lifestyle affect wound healing |
Smoking Alcohol drinking People who don’t exercise regularly |
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How does nutrition affect wound healing |
Lack of protein, carbs, vitamins and minerals |
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Name some chronic disease that affecting wound healing |
Diabetes Heart disease Immune disorders |
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Name some chronic disease that affecting wound healing |
Diabetes Heart disease Immune disorders |
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What is dehiscence |
Spontaneous opening of an incision |
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What is eviceration |
Protrusion of the internal organs through the incision |
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What is eviceration |
Protrusion of the internal organs through the incision |
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What is the clinical intervention if dehiscence or eviceration occurs |
Place patient supine Place a towel soaked in normal saline over the incision and viscera Notify the surgeon immediately and prepare the patient for a return to surgery |
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Name the wound complications |
Hemorrhage Infection Cellulitis Fistula Sinus Dehiscence Eviceration |
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What condition may occur if a hemorrhage is internal? |
Hypovolemic shock |
