NUR10005 - Wound Management
Exam Study Guide
Wound - Answer - A defect or break in the skin that results from physical, mechanical or
thermal damage or that develops as a result of the presence of an underlying medical or
physiological disorder
Wound assessment - Answer H = history
E = examination (TIMED acronym)
I = investigations (wound swab, blood tests)
D = diagnosis (aetiology and cont. factors)
I = interventions
T.I.M.E.D - Answer T = tissue (colour, necrotic/black, slough/yellow, infection/green
I = infection (5signs; pain, redness, warmth, odour, swelling)
M = moisture (macerated/ skin is wet/ white and pruney)
E = edges (rolled, red or dusky)
D = depth
Wound healing - Answer Hemostasis phase
Inflammatory phase
Proliferation phase
Maturation phase
Primary intention and secondary intention - Answer - skin tissue is approximated (closed
together), limited to no tissue loss and can be fixed with glue, stitches or staples
(minimal granulation and scarring)
- extensive tissue loss and you are unable to or should not approximate (join the skin
together), considerable tissue loss
Exam Study Guide
Wound - Answer - A defect or break in the skin that results from physical, mechanical or
thermal damage or that develops as a result of the presence of an underlying medical or
physiological disorder
Wound assessment - Answer H = history
E = examination (TIMED acronym)
I = investigations (wound swab, blood tests)
D = diagnosis (aetiology and cont. factors)
I = interventions
T.I.M.E.D - Answer T = tissue (colour, necrotic/black, slough/yellow, infection/green
I = infection (5signs; pain, redness, warmth, odour, swelling)
M = moisture (macerated/ skin is wet/ white and pruney)
E = edges (rolled, red or dusky)
D = depth
Wound healing - Answer Hemostasis phase
Inflammatory phase
Proliferation phase
Maturation phase
Primary intention and secondary intention - Answer - skin tissue is approximated (closed
together), limited to no tissue loss and can be fixed with glue, stitches or staples
(minimal granulation and scarring)
- extensive tissue loss and you are unable to or should not approximate (join the skin
together), considerable tissue loss
