Wound Care Final Exam Review

Wound Care Final Exam Review What cells located in the dermis produce collagen (dermal building blocks) and elastin (tensile strength)? - Fibroblasts A patient has an acute full-thickness wound due to trauma. What order of healing would occur with this wound? - hemostasis, inflammation, proliferation and maturation Which statement accurately describes the characteristic and implication of necrotic tissue in a wound bed? - Eschar usually is black, brown, or gray and associated with deeper tissue damage. It is usually firmly attached to the wound base. What is the primary reason for taking the time to perform a comprehensive assessment to identify protein energy malnutrition as opposed to ordering a simple blood draw to formulate a diagnosis? - Blood tests do not provide a stand alone assessment. This wound will heal with a scar formation. - full thickness wound When the skin around a wound develops a whitish appearance, it can be described as? - maceration. As you setup a skin care program, you identify the elderly to be at risk for skin tears due to the effects of aging on the: - rete ridges As wound healing progresses, collagen deposition and remodeling occur and has which of the following effects? - increased tensile strength You are aware that age itself is not a risk factor for failure to heal wounds. Problems in wound healing for the elderly are most likely associated with: - Multiple co-morbidities An intubated pt. with HOB elevated to 45 degrees. Has a stage 3 pressure ulcer on her coccyx with undermining. Which of the following risk factors is most responsible for undermining in the pressure injuries? - Shear from having the HOB elevated to 45 Degrees. Arterial disease, hypotension, vasopressors and severe anemia can be deleterious to wound healing because they decrease the amount of: - Oxygen in the tissue What cell plays a central role in initiating the wound repair process? - Platelets 90 Year old female in the nursing home has a partial thickness wound with a fully approximated epidermal flap on her left forearm. What type of skin damage is present - Skin tear, type 1 Which treatment would be most appropriate for the management of a partial thickness wound with a fully approximated epidermal flap? - Re-approximate edges and apply a non-adherent dressing When changing a wound dressing over a full thickness wound, you notice the wound bed is shiny, moist, red and has a cobblestone appearance. What terminology would you use to document this observation? - Granulation is present The 3 principles of wound care provide a useful format for prioritizing approaches in wound care. They are: - reduce/eliminate the cause of the wound, support the host and maintain a physiologic environment. As the wound care nurse specialist, you are teaching your skin care team about the importance of maintaining a physiologic wound environment. One of your nurses asks the question, "what is a physiologic environment for a wound?" The best response would be conditions established in the wound that: - Provide the wound with adequate moisture, pH regulation, control of temperature and bioburden As a specialist working in wound care, it is important to involve the patient in determining the goal for the wound. Some therapies are so time-consuming and expensive that patients may not continues to be adherent to protocols. What is an example of a goal for a wound? - Healing, maintenance (delayed healing) and comfort Of the following wound care strategies, which demonstrates knowledge of physiologic wound care? - Dressing change orders at intervals recommended by the manufacturer (usually every 3-4 days) or if leaking. which of the following debridement techniques is within the scope of practice of the WOC nurse and expedites the removal of a non-infective eschar covering a pressure injury? - Autolytic debridement What is indicative of a wound infection? - Friable red wound bed, increase in exudate production, periwound erythema and odor. Mr Carter is in ICU following coronary artery bypass graft surgery. He communicates that he is having significant pain. The incision on his upper right thigh is approximated and intact and covered with a transparent dressing: a slight redness is noted around the incision. What assessment place him at risk for impaired