Fundamental Nursing Skills and Concepts
Chapter 28 exam with complete solutions
This is damaged skin or soft tissue that occurs as a result of trauma Cuts, blows, poor
circulation, chemicals, excessive hot or cold - ANSWER-wound
this is the surface of skin or mucous membrane is not intact (could be accidental or
Intentional) - ANSWER-Wound OPEN
what is it called when there is no opening of skin or mucous membrane (exp blunt
trauma pressure) - ANSWER-Wound CLOSED
a clean separation of skin and tissue with smooth even edges - ANSWER-Incision
a separation of skin and tissue in which the edges are torn and separated and irregular -
ANSWER-Laceration
a wound in which the surface layers are scraped away - ANSWER-Abrasion
stripping away of large areas of skin and underlying tissue, leaving cartilage and bone
exposed - ANSWER-Avulsion
a shallow crater in which skin or mucous membranes is missing - ANSWER-Ulceration
this is an opening of skin, underlying tissue, or mucosus membrane caused by a narrow
sharp pointed object - ANSWER-Puncture
This is an injury to soft tissue underlying the skin from the force of contact with a hard
object, sometimes called a bruise. - ANSWER-Contusion (Closed Wounds)
What are the three phases of Wound Repair - ANSWER-1. Inflammation
,2. Proliferation
3. Remodeling
what is the physiologic defense immediately after tissue injury, last approximately 2-5
days - ANSWER-Inflammation
What is the purpose of inflammation - ANSWER-1. Limit the local damage
2. Remove injured cells and debris
3. Prepare the wound for healing
what is the inflammatory response in the first wave of Wound Repair - ANSWER-Local
changes occur; blood vessels constrict (control blood loss), then dilate, Platelets form
loose clot to control bleeding, Damaged cells become more permeable, releasing
plasma and chemical substances
Signs and symptoms of infection of wound include? - ANSWER-Swelling, Redness,
Warmth, Pain, Decreased function
what is the Second Wave of Defense inflammation - ANSWER--Leukocytes and
Macrophages (white blood cells) migrate to site of injury
-Body produces more to take their place,
- Leukocytosis confirmed confirmed and monitored through blood specimen
Blood test - ANSWER-WBC w/differential, Rise in neutrophils and monocytes suggests
inflammatory response or infectious process occurring
what are neutrophils and monocytes responsible for ? - ANSWER-phagocytosis of
pathogens, coagulation of blood and cellular debris
(They clean area of wound injury and prepare site for wound healing)
Period during which new cells fill and seal a wound; Occurs 2 days to 3 weeks after the
inflammation - ANSWER-Proliferation Phase 2 of Wound Repair
what is proliferation characterized by (phase 2) - ANSWER--Granulation tissue appear
- bright pink to red due to extensive capillaries
- grows from wound edge to center
- fragile and easily disrupted by physical or chemical means
- Collagen is produced by fibroblast
- adhesive strength of wound increases
-Blood vessels begin to shrink
- Pink color disappears
, what is granulation tissue - ANSWER-combo of new blood vessels, fibroblasts,
epithelial cells)
(main substance we see during proliferation along with collagen)
what is collagen - ANSWER-protein substance tough and inelastic
(main substance we see during proliferation along with granulation)
how is the integrity of skin is restored? - ANSWER-Resolution, Regeneration and scar
formation
process by which damaged cells recovers and re-establishes their normal function -
ANSWER-Resolution
cell duplication Scar formation replacement of damaged cells with fibrous tissue acts as
non functioning patch - ANSWER-Regeneration
replacement of damaged cells with a fibrous tissue, act as non functioning patch -
ANSWER-Scar Formation
this is the period during which the wound undergoes changes and maturation (Lasts 6
months to 2 years) - ANSWER-Remodeling Phase 3 of Wound Repair
what does the wound do during remodeling phase 3 - ANSWER-Wound contracts Scar
shrinks; scar is stronger, but not as strong as original tissue
what affects wound Healing ? - ANSWER--Type of wound injury
- Expanse or depth of wound
- Quality of circulation
- Amount of wound debris
- Presence of infection
- Status of the patient's health
- excessive pulling or tension on edges
what does the speed of wound healing depends on? - ANSWER-if wound repair takes
place and extent of scar tissue that forms
what is the key to wound healing? - ANSWER-Adequate blood flow to the injured tissue
what are the types of wound healing? - ANSWER-First intention, Second intention,
Third intention
Chapter 28 exam with complete solutions
This is damaged skin or soft tissue that occurs as a result of trauma Cuts, blows, poor
circulation, chemicals, excessive hot or cold - ANSWER-wound
this is the surface of skin or mucous membrane is not intact (could be accidental or
Intentional) - ANSWER-Wound OPEN
what is it called when there is no opening of skin or mucous membrane (exp blunt
trauma pressure) - ANSWER-Wound CLOSED
a clean separation of skin and tissue with smooth even edges - ANSWER-Incision
a separation of skin and tissue in which the edges are torn and separated and irregular -
ANSWER-Laceration
a wound in which the surface layers are scraped away - ANSWER-Abrasion
stripping away of large areas of skin and underlying tissue, leaving cartilage and bone
exposed - ANSWER-Avulsion
a shallow crater in which skin or mucous membranes is missing - ANSWER-Ulceration
this is an opening of skin, underlying tissue, or mucosus membrane caused by a narrow
sharp pointed object - ANSWER-Puncture
This is an injury to soft tissue underlying the skin from the force of contact with a hard
object, sometimes called a bruise. - ANSWER-Contusion (Closed Wounds)
What are the three phases of Wound Repair - ANSWER-1. Inflammation
,2. Proliferation
3. Remodeling
what is the physiologic defense immediately after tissue injury, last approximately 2-5
days - ANSWER-Inflammation
What is the purpose of inflammation - ANSWER-1. Limit the local damage
2. Remove injured cells and debris
3. Prepare the wound for healing
what is the inflammatory response in the first wave of Wound Repair - ANSWER-Local
changes occur; blood vessels constrict (control blood loss), then dilate, Platelets form
loose clot to control bleeding, Damaged cells become more permeable, releasing
plasma and chemical substances
Signs and symptoms of infection of wound include? - ANSWER-Swelling, Redness,
Warmth, Pain, Decreased function
what is the Second Wave of Defense inflammation - ANSWER--Leukocytes and
Macrophages (white blood cells) migrate to site of injury
-Body produces more to take their place,
- Leukocytosis confirmed confirmed and monitored through blood specimen
Blood test - ANSWER-WBC w/differential, Rise in neutrophils and monocytes suggests
inflammatory response or infectious process occurring
what are neutrophils and monocytes responsible for ? - ANSWER-phagocytosis of
pathogens, coagulation of blood and cellular debris
(They clean area of wound injury and prepare site for wound healing)
Period during which new cells fill and seal a wound; Occurs 2 days to 3 weeks after the
inflammation - ANSWER-Proliferation Phase 2 of Wound Repair
what is proliferation characterized by (phase 2) - ANSWER--Granulation tissue appear
- bright pink to red due to extensive capillaries
- grows from wound edge to center
- fragile and easily disrupted by physical or chemical means
- Collagen is produced by fibroblast
- adhesive strength of wound increases
-Blood vessels begin to shrink
- Pink color disappears
, what is granulation tissue - ANSWER-combo of new blood vessels, fibroblasts,
epithelial cells)
(main substance we see during proliferation along with collagen)
what is collagen - ANSWER-protein substance tough and inelastic
(main substance we see during proliferation along with granulation)
how is the integrity of skin is restored? - ANSWER-Resolution, Regeneration and scar
formation
process by which damaged cells recovers and re-establishes their normal function -
ANSWER-Resolution
cell duplication Scar formation replacement of damaged cells with fibrous tissue acts as
non functioning patch - ANSWER-Regeneration
replacement of damaged cells with a fibrous tissue, act as non functioning patch -
ANSWER-Scar Formation
this is the period during which the wound undergoes changes and maturation (Lasts 6
months to 2 years) - ANSWER-Remodeling Phase 3 of Wound Repair
what does the wound do during remodeling phase 3 - ANSWER-Wound contracts Scar
shrinks; scar is stronger, but not as strong as original tissue
what affects wound Healing ? - ANSWER--Type of wound injury
- Expanse or depth of wound
- Quality of circulation
- Amount of wound debris
- Presence of infection
- Status of the patient's health
- excessive pulling or tension on edges
what does the speed of wound healing depends on? - ANSWER-if wound repair takes
place and extent of scar tissue that forms
what is the key to wound healing? - ANSWER-Adequate blood flow to the injured tissue
what are the types of wound healing? - ANSWER-First intention, Second intention,
Third intention
