Name the phases of the wound healing process. 1. Inflammatory 2. Proliferative 3. Maturation
Wound caused by a blow to the body by a blunt object Contusion
A localized area of necrotic soft tissue that occurs when pressure is applied to the skin over time Pressure ulcer
Wound involving friction ...
CLIN APPS TEST 1 QUESTIONS AND ANSWERS Name the phases of the wound healing process. ✅1. Inflammatory 2. Proliferative 3. Maturation Wound caused by a blow to the body by a blunt object ✅Contusion A localized area of necrotic soft tissue that occurs when pressure is applied to the skin over time ✅Pressure ulcer Wound involving friction of skin; superficial ✅Abrasion Cut in the skin; wound edges may be smooth or jagged; depth may be shallow or deep ✅Laceration Intentional or unintentional penetrating trauma by sharp or pointed instrument that penetrates skin and underlying tissue ✅Puncture Closed wound; bleeding in underlying tissues from blunt blow; bruising ✅Contusion Name the 3 stages of the inflammatory response. ✅1. Arterioles constrict 2. Release of kinins 3. Permeability of cells Name the cardinal signs of inflammation: a local response. ✅1. Heat 2. Redness 3. Swelling 4. Pain 5. Loss of function Name the cardinal signs of inflammation: a systemic response. ✅1. Increased leucocytes 2. Malaise 3. Nausea 4. Anorexia 5. Increased pulse 6. Increased respiratory rate 7. Fever Name reasons for wound healing delay. ✅1. Infection 2. Hematoma 3. Foreign body 4. Necrosis 5. Low albumin level 6. Poor vascular supply (anemia) 7. Poor nutrition 8. Chronic medical condition (diabetes) 9. Mechanical distress (wound dehiscence) When does the inflammatory response occur once there is a wound? ✅Immediately What does the acronym TIME stand for? ✅T: tissue viable/non -viable I: infectious or inflamed M: moisture needed to heal E: edges List equipment needed for a wound assessment . ✅1. Gloves 2. Sterile saline 3. Tape measure 4. Sterile q -tips List the things a nurse needs to measure during a wound assessment. ✅1. Depth 2. Length 3. Width 4. Tunneling 5. Undermining What are the things a nurse needs to describe in the documentation of a wound? ✅1. Drainage type 2. Odor 3. Wound bed 4. Surrounding tissue 5. Skin temperature 6. Pain What are risk factors for skin breakdown? ✅1. Age 2. Disease 3. Infection 4. Incontinence 5. Immobility 6. Sensory loss 7. Poor nutrition 8. Friction & sheer 9. Heat 10. Moisture
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