WEB WOC WOUND CARE EXAM PREP
QUESTIONS AND ANSWERS FULL
SOLUTION STUDY SHEET
●● risk factors for pressure ulcer development and nursing interventions
to reduce ulcer development
Answer: SHEAR-keep HOB <30 degree angle. reposition frequency is
determined by tissue tolerance, lvl of activity, and mobility. std=every 1-
2 hrs for bed bound, every 1 hr for chair. use support surfaces to
redistribute wt
FRICTION-minimal layers of bed linens between pt and the surface.
keep heels off bed. teach pt's to reposition wt every 15 min. use
assisitive devices when transferring or turning pt.
MOISTURE-use an incontinence cleanser and moisture barrier cream,
toileting schedule, fecal incontinence collector or condom cath, use
underpads or diapers that wick moisture AWAY from skin rather than
trap it
NUTRITION-nutrition assessment, ensure adequate intake of
PROTEIN, fat, and carbs, consult RD, ensure adequate fluid intake
INFECTION-
,AGE-thin skin increases
●● Partial-thickness wound
Answer: wounds that heal by primary intention and shallow wounds that
only involve loss of epidermis/dermis
heal by resurfacing of wound with new epidermal cells
●● Partial-thickness wound repair
Answer: Inflammatory response-[erythema/edema inc WBC to site].
usually subsides in <24 hrs
Epidermal repair-[epidermal cells migrate across wound]. moist env-heal
in ~4days, dry env-heal in 7 days
Dermal repair-[epidermis thickens and anchors to cells]. resumes normal
fxn. pink, dry, and fragile skin. occurs concurrently w/ epidermal repair
●● Full-thickness wound
Answer: involve tissue loss and extend to at least
Sub Q layer. can be acute (surgical wound) or chronic (pressure ulcer)
, can be healed by primary or secondary intention
●● Full-thickness wound repair
Answer: Hemostasis-[controls bleeding]. platelets cause coag and
vasocontriction, and break down and release growth factors (GF initiate
entire wound healing process). DOES NOT occur in wounds healing by
secondary intention! (comprimises repair process)
Inflammation-[establish clean wound bed & bacterial balance]. brings
WBC to area, cleans site, releases addt'l GF. lasts 3 days in acute
wounds, >3 days in chronic wound (pressure ulcer)
Proliferation-[prod. of new tissue, epithelialization, contraction]. w/
primary intention new capillary networks form to provide O2 and
nutrients and synthesis of collagen. wound contracts as collagen fibers
increase in size. epithelial cells migrate and cover defect (occurs faster
in moist env!!!!). w/ pressure ulcer, takes longer. as granulation tissue
fills defect, contraction and epithelialization can occur. contraction is
more important in secondary wounds b/c it reduces amnt of granulation
tissue needed to fill defect!!!
Remodeling-[reorganizes collagen to produce more elastic, stronger
collagen for scar tissue]. lasts up to 1 year. tensile strength never more
than 80% or non-damaged tissue. remodeling phase is same for primary
and secondary intention wounds
QUESTIONS AND ANSWERS FULL
SOLUTION STUDY SHEET
●● risk factors for pressure ulcer development and nursing interventions
to reduce ulcer development
Answer: SHEAR-keep HOB <30 degree angle. reposition frequency is
determined by tissue tolerance, lvl of activity, and mobility. std=every 1-
2 hrs for bed bound, every 1 hr for chair. use support surfaces to
redistribute wt
FRICTION-minimal layers of bed linens between pt and the surface.
keep heels off bed. teach pt's to reposition wt every 15 min. use
assisitive devices when transferring or turning pt.
MOISTURE-use an incontinence cleanser and moisture barrier cream,
toileting schedule, fecal incontinence collector or condom cath, use
underpads or diapers that wick moisture AWAY from skin rather than
trap it
NUTRITION-nutrition assessment, ensure adequate intake of
PROTEIN, fat, and carbs, consult RD, ensure adequate fluid intake
INFECTION-
,AGE-thin skin increases
●● Partial-thickness wound
Answer: wounds that heal by primary intention and shallow wounds that
only involve loss of epidermis/dermis
heal by resurfacing of wound with new epidermal cells
●● Partial-thickness wound repair
Answer: Inflammatory response-[erythema/edema inc WBC to site].
usually subsides in <24 hrs
Epidermal repair-[epidermal cells migrate across wound]. moist env-heal
in ~4days, dry env-heal in 7 days
Dermal repair-[epidermis thickens and anchors to cells]. resumes normal
fxn. pink, dry, and fragile skin. occurs concurrently w/ epidermal repair
●● Full-thickness wound
Answer: involve tissue loss and extend to at least
Sub Q layer. can be acute (surgical wound) or chronic (pressure ulcer)
, can be healed by primary or secondary intention
●● Full-thickness wound repair
Answer: Hemostasis-[controls bleeding]. platelets cause coag and
vasocontriction, and break down and release growth factors (GF initiate
entire wound healing process). DOES NOT occur in wounds healing by
secondary intention! (comprimises repair process)
Inflammation-[establish clean wound bed & bacterial balance]. brings
WBC to area, cleans site, releases addt'l GF. lasts 3 days in acute
wounds, >3 days in chronic wound (pressure ulcer)
Proliferation-[prod. of new tissue, epithelialization, contraction]. w/
primary intention new capillary networks form to provide O2 and
nutrients and synthesis of collagen. wound contracts as collagen fibers
increase in size. epithelial cells migrate and cover defect (occurs faster
in moist env!!!!). w/ pressure ulcer, takes longer. as granulation tissue
fills defect, contraction and epithelialization can occur. contraction is
more important in secondary wounds b/c it reduces amnt of granulation
tissue needed to fill defect!!!
Remodeling-[reorganizes collagen to produce more elastic, stronger
collagen for scar tissue]. lasts up to 1 year. tensile strength never more
than 80% or non-damaged tissue. remodeling phase is same for primary
and secondary intention wounds
