Wound Care and Skin Integrity Flashcards

When performing wound irrigation, which pressure range effectively removes debris without causing tissue damage?

Answer: 4–15 psi

Irrigation pressure of 4–15 psi is sufficient to dislodge debris and bacteria while avoiding trauma to fragile healing tissue.

Which characteristic of wound drainage is most indicative of an active infection?

Answer: Purulent (thick, cloudy, foul-smelling) drainage

Purulent exudate is thick, cloudy, and often malodorous, reflecting bacterial colonization and an active infectious process.

A wound that has not progressed through the normal healing stages after 4 weeks is classified as a(n):

Answer: Chronic wound

A chronic wound is defined by failure to heal within an expected timeframe, generally more than 4 weeks without meaningful progress.

What is the primary purpose of a wet-to-dry dressing?

Answer: Perform mechanical debridement of necrotic tissue

Wet-to-dry dressings adhere to necrotic tissue as they dry and remove it mechanically when the dressing is changed.

Which agent is most commonly used for enzymatic (chemical) debridement of necrotic wound tissue?

Answer: Collagenase (Santyl)

Collagenase (Santyl) is an enzymatic debriding agent that selectively breaks down necrotic collagen without harming healthy tissue.

When documenting a wound assessment, which set of data is MOST important for the LPN to record?

Answer: Wound location, size, depth, exudate type, and tissue type in the wound bed

Complete wound documentation requires objective measurements and descriptive data including location, dimensions, depth, exudate, and tissue type to track healing progress.

To accurately measure wound depth during assessment, the LPN should:

Answer: Insert a sterile cotton-tipped swab perpendicularly into the deepest part of the wound

A sterile cotton-tipped swab inserted perpendicularly to the deepest point of the wound is the standard technique for measuring wound depth.