Exam (elaborations)
PN 103-11 WOUND CARE EXAM
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PN 103-11 WOUND CARE EXAM...
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Contusion - ANSWER A closed, discolored wound caused by blunttrauma; a bruise
Abrasion - ANSWER Superficial open wound; a scrape or scratch
Puncture Wound - ANSWER Open wound that results when sharp item
pierces the skin that extends to deeper tissues according to the diameter
and length of the impending sharp item
Laceration - ANSWER Open wound made by the accidental cutting or
tearing of tissue - jagged edges
Pressure Injuries - ANSWER Wound resulting from pressure and friction.
May or may not be intact with open areas
Open wound - ANSWER Skin integrity has been breached
Closed wound - ANSWER The skin remains intact.
Clean wound - ANSWER not infected
Clean-contaminated wound - ANSWER Surgically made and it is not
infected - more potential to become infected - normal flora of the GI,
Respiratory, and Urinary tracts
Contaminated wound - ANSWER Grossly contaminated by breaking
asepsis - surgical wounds or wounds caused by trauma
Infected wounds - ANSWER Infectious process is already established -
purulent drainage or necrotic tissue. classic signs: erythema, increased
warmth, edema, pain, odor, and drainage
, Colonized wounds - ANSWER microorganisms present with no signs of
infection
External pressure - ANSWER exerted on soft tissues for a prolonged
period (especially on bony prominences), tissues and capillaries are
compromised causing ischemia which leads to tissues necrosis.
Ischemia - ANSWER decreased blood flow to an area, deprives involved
area, eventually cells will necrose and die
Necrosis - ANSWER tissue death
Shearing - ANSWER the patient's skin and another item such as bed
linens or the surface of a chair, move in the opposite directions while
they are being pressed together by the body weight - the movement
causes friction which can pull tissues apart or sheer them from the body
What is the main cause of pressure injuries? - ANSWER External
pressure or friction and shearing
Where are the most common sites for pressure injuries to develop? -
ANSWER Bony prominences
Bony prominences - ANSWER sacrum, greater trochanter, buttox,
elbows, heals, ankles, scapulae, back of the head
Stage 1 - ANSWER Intact skin - erythema over a bony prominence,
does not blanch
Stage 2 - ANSWER Partial-thickness loss and exposed dermis, intact
serum filled blisters and broken blisters - subcutaneous is not visible
Stage 3 - ANSWER Full- thickness loss involving damage to the
epidermis, dermis, and subcutaneous tissue. does NOT involve bone
and muscle
Stage 4 - ANSWER Full-thickness skin and tissue loss - involves deep
tissue necrosis of muscle, fascia, tendon, joint capsule, and bone
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