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Wound Care –Questions With Complete Solutions (A+)
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Wound Care –Questions With Complete Solutions (A+)Skin integrity Right Ans - -open: break in skin/mucous membrane
ex. surgical insicsion, vena pucture, injection
-closed: no break in skin
ex. bone fracture, visceral organ damage
-acute: heal in orderly & timely manner, happen suddenly, disrupts blood
vessels, series of events w wound clotting and closure, 3-4 week heal, need
little intervention
ex. stab wound, paper cut, surgical incision
-chronic: does not heal in orderly & timely manner, occur over time , not
suddenly, take long time to heal, there are complications in healing, does not
involve clotting, need a lot of intervention
ex. decubitus ulcer
Cause of wound Right Ans - -intentional: results from therapy
ex. surgical incision
-unintentional: wound occur unexpectedly
ex. gun shot, paper cut, burn, stab
Severity Right Ans - -superficial: involve epidermis layer
ex. scrapes
-penetrating: thru dermis-> deep tissue
-perforating: foreign object enter/exit organ
Cleanliness Right Ans - depends on the organ
-treat body cavity as sterile during surgery bc easy to contaminate w microbes
-but it is not sterile
-clean: no pathogen ex. heart, kidney, thyroid
-clean-contaminated: made under sterile condition into body cavity that
normally have microbes ex. bowel has e.coli
-contaminated: microbes are likey, but dont know until open organ ex.
rupture appendix, abscess
-infected: any wound that doesnt properly heal, organisms can be cultured out
of wound ex. MRSA
-colonized: has organisms but no S/S
Descriptive qualities Right Ans - laceration: heal by irregular wound edges,
ex. skin tear. not a clean wound. hard to suture edges
,-abrasion: superficial wound from scraping
-contusion: caused by blow to body, bruise, swelling, discoloration, pain ex.
boxers, wrestlers, football
Inflammation process Right Ans - body's protection response from
infection, help promote healing
-from trauma (bruising), stab wound, splinter, foreign microbe
Inflammation characteristics Right Ans - -localized: isolated to area of
injury, protected
-adaptive: body is responding to a stressor (foreign microbe, pathogen)
-short-term
-restorative: body turns back to original state
Cardinal signs of inflammation Right Ans - -edema
-redness
-warmth
-pain
-loss of function
Vascular and cellular response Right Ans - -histamine
-kinis
-WBC
Histamine Right Ans - cause red-flushing, decrease BP, increase gastric
secretion
-produced from amino acid histidine
- increase WBC, and blood flow-> increase vol-> redness & warmth
-response to inflammation
-released by injured cells
Kinis Right Ans - polypeptides (AA)
-increase capillary permeability, more porous so WBC and plasma can leak out
to injured tissue
-movemt of fl cause sewlling and pain
WBC Right Ans - -fight infection and react against foreign bodies/tissue
-WBC is always 100%
, -types:
neutrophil 60% of WBC: in blood, ingest bacteria (phagocytosis), arrive 1st at
wound
lymphocytes 30%: immunity
monocytes 6%: clean debri (dead cells), become macrophages
eosinophils 3%: transport histamine, high in allergy rxn
basophils 1%: transport histamine, produce heparin to prevent clots
High WBC Right Ans - 10k+
-indicate inflammation, infection, tissue necrosis, leukemic neoplasia
-stress/ trauma in person
Body response to inflammation Right Ans - blood and cells
drainage
repair
cell-mediated immunity
Wound drainage Right Ans - fl and dead cells (dying neutrophils),
identified by color
-sanguineous: bright red blood, bleeding, in fresh wound
-serosanguineous: pale, red, watery, mixture of red/clear, wound after couple
days
-serous: clear/yellow, watery, after serosanguineous
-purulent: thick yellow, green, tan, brown, in infection, usually have smell,
color caused by organism
-pressure of fl on skin-> drainage-> can cause abscess
Repair Right Ans - scar: replace orginal tissue that was lost, not functional,
can cause wound contractures
-regeneration: replace w new scars
Cell-mediated immunity Right Ans - -t-lymphocytes: go to injury->attack
antigens, help immune response
-b-lymphocytes: produce antibodies
Primary intention Right Ans - -majority of surgical wounds
-incision: clean, straight line w all layers aprroximated by suturing
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