Wound Care Flashcards

The respiratory, alimentary, vaginal, or urinary tracts have been exposed by these surgical wounds:

Answer: Clean-contaminated wounds

Clean-contaminated wounds are surgical wounds where the respiratory, alimentary, vaginal, or urinary tracts are entered under controlled conditions. While these tracts contain normal flora, the controlled entry means the risk of infection is higher than a clean wound but lower than a contaminated or dirty wound.

To allow edema, infection, or exudate to drain, such wounds are left open for 3 to 5 days.

Answer: Tertiary healing

Tertiary healing, also known as delayed primary closure, involves leaving a wound open for 3 to 5 days to allow for drainage of edema, infection, or exudate. Once the risk of complications has subsided, the wound edges are then surgically approximated for closure.

This hemorrhagic exudate contains numerous red blood cells (RBCs) and shows significant capillary injury.

Answer: Sanguineous

Sanguineous exudate is characterized by its red, bloody appearance due to the presence of numerous red blood cells. This type of exudate indicates significant capillary injury and is commonly seen in fresh wounds or when there is considerable tissue trauma.

Subcutaneous tissue may be damaged or necrosed during full-thickness skin loss.

Answer: Stage III

A Stage III pressure ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Damage or necrosis of subcutaneous tissue is a defining characteristic of this stage, indicating a deeper level of tissue destruction.

Which of the following is a method of pressure ulcer prevention?

Answer: Frequent toileting

Both frequent toileting and providing nutritional supplements are effective methods for pressure ulcer prevention. Frequent toileting reduces skin exposure to moisture from incontinence, a key risk factor for skin breakdown. Adequate caloric and protein intake through supplements helps maintain skin integrity and supports tissue repair, as malnutrition increases susceptibility to pressure ulcers.

What symptoms and indicators indicate a wound that is infected?

Answer: Fever, purulent drainage, foul odor, discoloration of wound bed, and macerated wound edges

The correct answer lists classic signs of wound infection. Fever indicates a systemic response, while purulent drainage (pus), foul odor, and discoloration of the wound bed are direct indicators of bacterial presence and tissue compromise within the wound. Macerated wound edges suggest excessive moisture, which can further promote bacterial growth and impede healing.

Which of the following are pressure ulcer risk factors?

Answer: All of the above

All listed factors significantly increase the risk of pressure ulcer development. Decreased mental status impairs a patient's ability to perceive pressure and reposition, while fecal and urinary incontinence introduce moisture and bacteria, leading to skin breakdown. Excessive body heat can increase metabolic demand and perspiration, contributing to skin maceration and vulnerability, making 'All of the above' the correct choice.