NURS 205: WEEK 5 WOUND
ASSESSMENT & MANAGEMENT
QUESTIONS AND CORRECT
ANSWERS
5 main physiological functions of the skin ✅✅correct answ-- protection
-sensation/perception
-storage (fat/water)
-absorption (water, chemicals (topical meds)
-heat regulation (sweat)
structure of skin ✅✅correct answ-- epidermis: no blood vessels
-dermis: blood vessels, lymph & nerve
-subcutaneous tissue: fat tissue
wound ✅✅correct answ-- creates an alteration/disruption of the skin
classificatiions:
1. cause (surgical vs non-surgical)
2. duration (acute vs chronic)
3. depth of tissue affected
4. color of wound
surgical vs non surgical wounds ✅✅correct answ-surgical:
,- intentional
- clean cut
non-surgical:
- more likely to get infected
- usually by accident
acute wound ✅✅correct answ-- any surgical wound that heals by primary intention or any
traumatic/ surgical wound that heals by secondary intention
-"expected to progress through the phases of normal healing, resulting in the closure of the wound
- close by mechanical means> sutures, glue, steristrips
secondary: bottom up, outside in
-esentially healed in a timely manner, 3-4 weeks
chronic wounds ✅✅correct answ-- wound that fails to progress healing or respond to treatment
over the normal expected healing time frame (3-4 weeks), and becomes "stuck" in the inflammatory
phase
-this pathologic inflammation is due to a postponed, incomplete or uncoordinated healing process
-wound healing is delayed by presence of intrinsic and extrinsic factors including meds, poor
nutrition, co-morbidities, or inappropriate dressing selection
classification of chronic wounds ✅✅correct answ-- vascular (venous or arterial)
-neuropathic (diabetic)
-pressure injury
, factors that can impact (chronic) wound healing ✅✅correct answ-Smoking can impair wound
healing
- Impaired perfusion
- Smoking causes vasoconstriction
- Decrease oxygenation of tissues
- Need O2 to heal
- Encourage smoking cessation in chronic wound pt
Comorbidities can impact wounds
- Diabetes: proper glucose management, nutrition
Poor wound care management
- Inappropriate dressing of wounds
Medications can impact healing
- Anticoagulants
- Nicotine (vasoconstriction- decrease perfusion)
- Autoinflammatory: NSAIDS, corticosteroids
- Immunosuppressant: organ transplant patients
-Immunomodulators; diff autoimmune disorders
- chemotherapy
level of contamination ✅✅correct answ-classified according to bacterial contamination
- clean wound: operative incisional wound w no inflammation
-clean/contaminated wound: no inflammation encountered, but respiratory GI, urinary tract has
been entered (under controlled conditions w out unusual contamination)
-contaminated wound: open, traumatic wounds or surgical wounds involing a major break in sterile
technique showing evidence of inflammation
ASSESSMENT & MANAGEMENT
QUESTIONS AND CORRECT
ANSWERS
5 main physiological functions of the skin ✅✅correct answ-- protection
-sensation/perception
-storage (fat/water)
-absorption (water, chemicals (topical meds)
-heat regulation (sweat)
structure of skin ✅✅correct answ-- epidermis: no blood vessels
-dermis: blood vessels, lymph & nerve
-subcutaneous tissue: fat tissue
wound ✅✅correct answ-- creates an alteration/disruption of the skin
classificatiions:
1. cause (surgical vs non-surgical)
2. duration (acute vs chronic)
3. depth of tissue affected
4. color of wound
surgical vs non surgical wounds ✅✅correct answ-surgical:
,- intentional
- clean cut
non-surgical:
- more likely to get infected
- usually by accident
acute wound ✅✅correct answ-- any surgical wound that heals by primary intention or any
traumatic/ surgical wound that heals by secondary intention
-"expected to progress through the phases of normal healing, resulting in the closure of the wound
- close by mechanical means> sutures, glue, steristrips
secondary: bottom up, outside in
-esentially healed in a timely manner, 3-4 weeks
chronic wounds ✅✅correct answ-- wound that fails to progress healing or respond to treatment
over the normal expected healing time frame (3-4 weeks), and becomes "stuck" in the inflammatory
phase
-this pathologic inflammation is due to a postponed, incomplete or uncoordinated healing process
-wound healing is delayed by presence of intrinsic and extrinsic factors including meds, poor
nutrition, co-morbidities, or inappropriate dressing selection
classification of chronic wounds ✅✅correct answ-- vascular (venous or arterial)
-neuropathic (diabetic)
-pressure injury
, factors that can impact (chronic) wound healing ✅✅correct answ-Smoking can impair wound
healing
- Impaired perfusion
- Smoking causes vasoconstriction
- Decrease oxygenation of tissues
- Need O2 to heal
- Encourage smoking cessation in chronic wound pt
Comorbidities can impact wounds
- Diabetes: proper glucose management, nutrition
Poor wound care management
- Inappropriate dressing of wounds
Medications can impact healing
- Anticoagulants
- Nicotine (vasoconstriction- decrease perfusion)
- Autoinflammatory: NSAIDS, corticosteroids
- Immunosuppressant: organ transplant patients
-Immunomodulators; diff autoimmune disorders
- chemotherapy
level of contamination ✅✅correct answ-classified according to bacterial contamination
- clean wound: operative incisional wound w no inflammation
-clean/contaminated wound: no inflammation encountered, but respiratory GI, urinary tract has
been entered (under controlled conditions w out unusual contamination)
-contaminated wound: open, traumatic wounds or surgical wounds involing a major break in sterile
technique showing evidence of inflammation
