p.40
Wound Assessment Methodologies
What does a green color indicate in a sacral sore?
The presence of infection.
What is a key characteristic of an arterial ulcer?
Absent or weak distal pulses.
p.46
Staging of Pressure Injuries
What characterizes a Stage 4 pressure injury?
Full-thickness skin and tissue loss.
p.18
Methods of Wound Closure
How do wider wounds epithelialize during secondary intention healing?
From the periphery and remnants of skin appendages such as sweat glands, hair follicles, and sebaceous glands.
p.25
Pathophysiology of Pressure Ulcers
What is the main cause of pressure exerted on bony prominences?
Pressure mainly attributed to body weight.
p.36
Phases of Wound Healing
What does a pink color indicate in wound healing?
It indicates epithelialization, a phase where new skin cells are forming.
p.24
Pathophysiology of Pressure Ulcers
How does direct pressure of body weight contribute to pressure ulcers?
It restricts blood flow to the skin and underlying tissues, leading to tissue damage.
p.45
Staging of Pressure Injuries
What is a characteristic of a Stage 3 pressure injury?
Full thickness skin loss.
p.57
Wound Assessment Methodologies
What are the characteristics of exudate that need to be documented during wound assessment?
Amount, odour, and colour.
p.43
Staging of Pressure Injuries
What characterizes a Stage 1 pressure injury?
Persistent non-blanchable erythema of intact skin.
p.17
Methods of Wound Closure
What type of wound healing involves a wound with minimal gap?
Primary intention healing.
Where are venous ulcers commonly located?
On the medial aspect of the leg.
p.56
Wound Assessment Methodologies
What is planimetry?
Planimetry is the measurement of plane surfaces.
p.59
Wound Assessment Methodologies
What does a foul smell, purulent, greenish exudate indicate in a wound?
It indicates wound infection or colonization.
p.59
Management of Chronic Wounds
What actions should be taken if a wound shows signs of infection or colonization?
More frequent cleansing, use of antiseptic solution, or surgical debridement of necrotic tissue.
p.26
Pathophysiology of Pressure Ulcers
When does tissue necrosis and pressure ulcer formation occur?
Tissue necrosis and pressure ulcer formation occur when the ischaemic insult is irreversible.
p.41
Staging of Pressure Injuries
Why is a staging system needed in wound assessment?
For better communication and management.
p.50
Wound Assessment Methodologies
What are the two types of dimensional assessments for wound size?
2 dimensional and 3 dimensional, including undermining.
p.4
Classification of Wounds by Chronicity
How is a chronic wound defined in terms of healing time?
A wound that fails to heal in 6 weeks is regarded as chronic.
p.10
Physiology of Wound Healing
What type of wound healing occurs in fetuses?
Regeneration, resulting in no scar.
p.15
Physiology of Wound Healing
What does epithelialization refer to in the context of wound healing?
The process by which new epithelial cells form and cover a wound.
p.18
Methods of Wound Closure
What type of healing is associated with wider wounds?
Secondary intention healing.
p.24
Pathophysiology of Pressure Ulcers
How does shearing and friction on movement contribute to pressure ulcers?
They cause the skin to stretch and tear, damaging the underlying tissues.
p.27
Pathophysiology of Pressure Ulcers
How is pressure determined?
Pressure is determined by the formula: Pressure α load / contact area.
p.28
Pathophysiology of Pressure Ulcers
What is the maximal limit to reverse tissue damage due to local pressure?
2 hours, according to studies.
p.64
Wound Assessment Methodologies
Why is wound assessment methodology important?
Wound assessment methodology is crucial for accurately diagnosing the wound type, determining the appropriate treatment plan, and monitoring healing progress.
p.61
Management of Chronic Wounds
What should be done if a chronic wound has purulent exudates and necrotic devitalized tissue?
Debridement and drainage.
p.38
Wound Assessment Methodologies
What does yellow slough indicate in wound assessment?
Yellow slough indicates wet, necrotic tissue.
p.35
Classification of Wounds by Chronicity
What does a pink color indicate in a wound?
It indicates that the wound is epithelializing.
p.52
Wound Assessment Methodologies
Why is measuring the greatest length and width of a wound considered a 2D assessment?
Because it only involves measuring the length and width, not the depth.
What is a common feature of the skin surrounding venous ulcers?
Surrounding pigmentation.
p.25
Pathophysiology of Pressure Ulcers
What forces contribute to pressure ulcers besides body weight?
Shearing force and friction from movement and turning over the bedding.
p.64
Physiology of Wound Healing
What are the general and local factors affecting wound healing?
General factors include age, nutrition, and systemic diseases, while local factors include infection, blood supply, and the presence of foreign bodies.
p.11
Methods of Wound Closure
What is primary intention in wound closure?
A method where wound edges are brought together to heal, typically used for acute, clean wounds.
p.11
Methods of Wound Closure
For what type of wounds is primary intention seldom possible?
Chronic, contaminated wounds.
p.28
Management of Chronic Wounds
What is the general guideline for turning patients to prevent pressure ulcers?
Q2H turning (every 2 hours).
p.19
Phases of Wound Healing
What is epithelialization in wound healing?
Epithelialization is the process where new epithelial cells form and migrate to cover a wound.
p.37
Phases of Wound Healing
What is a granulating wound?
A wound that is in the process of forming new tissue and blood vessels, typically appearing red and moist.
p.37
Phases of Wound Healing
What does the red color in a granulating wound indicate?
The presence of new tissue and blood vessels, indicating healing.
p.26
Pathophysiology of Pressure Ulcers
What causes tissue ischaemia in the context of pressure ulcers?
Tissue ischaemia occurs when external pressure exceeds capillary pressure (35mmHg).
p.64
Pathophysiology of Pressure Ulcers
How do direct pressure, friction, and shearing forces contribute to pressure injury formation?
Direct pressure restricts blood flow, friction damages the skin surface, and shearing forces cause deeper tissue damage, all contributing to pressure injury formation.
p.27
Pathophysiology of Pressure Ulcers
What effect does minimal surface contact area have on pressure?
Minimal surface contact area increases pressure due to the loss of the padding effect of soft tissue.
p.28
Pathophysiology of Pressure Ulcers
What determines the ability of tissue to withstand local pressure and ischaemia?
The ability of tissue to withstand local pressure and ischaemia varies based on individual factors such as weight and wound healing power.
p.58
Wound Assessment Methodologies
How is the amount of exudate typically assessed?
It is usually assessed subjectively.
p.6
Pathophysiology of Pressure Ulcers
What is meant by a 'pressure area' in the context of pressure ulcers?
A pressure area is a region of the body that is at risk of developing pressure ulcers due to prolonged pressure, often over bony prominences.
p.33
Wound Assessment Methodologies
What does a yellow wound appearance indicate?
Sloughing (darker when dry).
p.51
Wound Assessment Methodologies
What is the simplest practice for measuring a wound?
Measuring the greatest length and width.
p.24
Pathophysiology of Pressure Ulcers
What are the two main causes of pressure ulcers?
Direct pressure of body weight and shearing/friction on movement.
p.56
Wound Assessment Methodologies
What is the significance of using 1cm x 1cm in planimetry?
It provides a standardized unit for measuring and comparing surface areas.
p.53
Wound Assessment Methodologies
What does 'undermined part of the wound' refer to?
Areas where the tissue under the wound edges is eroded, creating a pocket.
p.57
Wound Assessment Methodologies
Why is it important to document the amount of exudate in wound assessment?
The amount of exudate can indicate the level of wound healing or infection.
p.45
Staging of Pressure Injuries
Which structures are NOT exposed in a Stage 3 pressure injury?
Fascia, muscle, tendon, ligament, cartilage, and/or bone.
p.57
Wound Assessment Methodologies
How can the colour of exudate be significant in wound assessment?
The colour can provide clues about the type of exudate and the stage of healing or infection.
p.20
Phases of Wound Healing
What happens to collagen content during the remodeling phase?
Collagen content is reorganized and strengthened.
p.22
Pathophysiology of Pressure Ulcers
What is a pressure ulcer?
Localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.
p.31
Wound Assessment Methodologies
Why is it important to assess rehabilitation and risks of recurrence in wound care?
To develop a plan that promotes healing and prevents future wounds.
p.12
Methods of Wound Closure
How does epithelialization occur in secondary intention wound healing?
Epithelialization occurs from the periphery of the wound.
p.32
Wound Assessment Methodologies
What should be assessed about the 'Surrounding skin' in wound documentation?
The condition of the skin around the wound, including color, temperature, and integrity.
p.47
Staging of Pressure Injuries
What are the characteristics of stable eschar?
Dry, adherent, intact without erythema or fluctuance.
p.32
Wound Assessment Methodologies
What does 'Septic/Infective status' indicate in wound assessment?
The presence of infection or signs of sepsis in the wound.
p.60
Wound Assessment Methodologies
Why is it important to keep the dressing for inspection when dealing with exudate?
To assess the amount, color, and consistency of the exudate, which can provide valuable information about the wound's condition and healing progress.
p.52
Wound Assessment Methodologies
What dimensions are measured when assessing the greatest length and width of a wound?
Only the 2D dimensions (length and width).
p.46
Staging of Pressure Injuries
What structures may be exposed or directly palpable in a Stage 4 pressure injury?
Fascia, muscle, tendon, ligament, cartilage, or bone.
p.5
Classification of Wounds by Chronicity
What are some examples of chronic wounds?
Examples of chronic wounds include diabetic ulcers, venous ulcers, arterial ulcers, and pressure ulcers.
p.27
Pathophysiology of Pressure Ulcers
What factors increase pressure?
Increased weight of the patient (load) and minimal surface contact area, loss of padding effect of soft tissue (area).
p.26
Pathophysiology of Pressure Ulcers
What are the two main factors contributing to ulcer formation?
The two main factors are pressure and duration of pressure.
p.44
Staging of Pressure Injuries
What does the wound bed look like in a Stage 2 pressure injury?
The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.
p.54
Wound Assessment Methodologies
What does mapping of the wound edge involve?
It involves outlining the edges of the wound to assess its size and shape.
p.6
Pathophysiology of Pressure Ulcers
What is a pressure ulcer?
A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear.
p.34
Phases of Wound Healing
What is epithelialising in the context of wound healing?
Epithelialising is the process where new epithelial cells form over a wound, indicating the final stage of healing where the wound is closing.
p.34
Phases of Wound Healing
What does granulating mean in wound healing?
Granulating refers to the formation of new connective tissue and tiny blood vessels that fill the wound bed, indicating the wound is healing.
p.58
Wound Assessment Methodologies
What type of dressing frequency is recommended for a wound with minimal exudate?
Daily dressing changes are recommended for minimal exudate.
p.12
Methods of Wound Closure
What is secondary intention in wound healing?
It is a process where the wound heals by granulation tissue filling up the space and epithelialization from the periphery, often involving chronic wounds with tissue loss and separated edges.
p.9
Phases of Wound Healing
What key processes occur during the proliferative phase of wound healing?
Tissue formation, angiogenesis, collagen deposition, and wound contraction.
p.32
Wound Assessment Methodologies
What does 'Size' refer to in wound assessment?
The dimensions of the wound, including length, width, and depth.
p.32
Wound Assessment Methodologies
What does 'Appearance' refer to in wound assessment?
The visual characteristics of the wound bed, including color, tissue type, and presence of necrosis.
p.29
Importance of Nutritional and Psychosocial Assessment in Wound Care
What conditions contribute to poor wound healing?
Sepsis, malnutrition, malignancy, organ failure, vascular insufficiency, and diabetes.
p.19
Phases of Wound Healing
What role do skin appendages in the dermis play in epithelialization?
Skin appendages in the dermis contribute to epithelialization by providing a source of new epithelial cells.
p.53
Wound Assessment Methodologies
What additional aspect should be documented when assessing a wound?
The undermined part of the wound.
p.53
Wound Assessment Methodologies
What should be noted about the wound base during assessment?
The condition of the wound base.
p.59
Wound Assessment Methodologies
Can some wound care products produce a characteristic smell without indicating infection?
Yes, some products like duoderm may produce a smell due to autolysis of the wound and may not imply infection.
p.44
Staging of Pressure Injuries
What characterizes a Stage 2 pressure injury?
Partial-thickness skin loss with exposed dermis.
p.27
Pathophysiology of Pressure Ulcers
What happens to pressure when the weight of the patient increases?
Pressure increases with the increased weight of the patient (load).
p.34
Phases of Wound Healing
What is necrotic tissue in the context of wound healing?
Necrotic tissue is dead tissue that is often black or brown and may be hard or soft. It needs to be removed for proper wound healing.
p.44
Staging of Pressure Injuries
Are adipose (fat) and deeper tissues visible in a Stage 2 pressure injury?
No, adipose (fat) and deeper tissues are not visible.
p.4
Classification of Wounds by Chronicity
Why is it important to know the underlying cause of a chronic wound?
Because chronic wounds are more difficult to manage.
p.54
Wound Assessment Methodologies
What is planimetry in the context of wound assessment?
Planimetry is a technique used to estimate the area of a wound by measuring its dimensions.
p.22
Pathophysiology of Pressure Ulcers
How can a pressure ulcer present itself?
As intact skin or an open ulcer and may be painful.
p.16
Phases of Wound Healing
What role does epithelialization play in temperature regulation?
It helps re-establish the skin's barrier functions, which are crucial for temperature regulation.
p.58
Wound Assessment Methodologies
What type of dressing frequency is recommended for a wound with moderate exudate?
Twice daily (BD) dressing changes are recommended for moderate exudate.
p.33
Wound Assessment Methodologies
Is it possible for a wound to have a mixture of colors?
Yes, a mixture of colors over variable sites is possible.
p.9
Phases of Wound Healing
What is the final phase of wound healing?
The remodeling or maturation phase.
p.62
Management of Chronic Wounds
What is erythema and how does it relate to wound healing?
Erythema is redness of the skin caused by increased blood flow, and it can indicate inflammation or infection, affecting wound healing.
p.49
Management of Chronic Wounds
What is the recommended intervention for Stage 3 and 4 pressure ulcers?
Surgical intervention to enhance wound closure if feasible.
p.29
Pathophysiology of Pressure Ulcers
Why are patients in intensive care or post-operation at high risk for pressure injuries?
They may be unable to move or turn themselves, increasing the risk of pressure injuries.
p.21
Staging of Pressure Injuries
How are pressure ulcers classified?
Pressure ulcers are classified into four stages based on the depth of tissue damage: Stage 1 (non-blanchable erythema), Stage 2 (partial-thickness skin loss), Stage 3 (full-thickness skin loss), and Stage 4 (full-thickness tissue loss).
p.19
Phases of Wound Healing
Where does epithelialization primarily occur during wound healing?
From the periphery and remnants of skin appendages.
p.53
Wound Assessment Methodologies
What dimensions should be measured when assessing a wound?
The greatest length and width.
p.42
Staging of Pressure Injuries
What is the characteristic of a Stage 1 pressure injury according to the National Pressure Ulcer Advisory Panel 2016?
Persistent non-blanchable erythema of intact skin.
p.42
Staging of Pressure Injuries
What defines a Stage 2 pressure injury?
Partial-thickness skin loss with exposed dermis.
p.41
Staging of Pressure Injuries
How are wounds classified in staging?
According to various depths of tissue involvement.
p.42
Staging of Pressure Injuries
What defines a Stage 4 pressure injury?
Full-thickness skin and tissue loss.
p.34
Phases of Wound Healing
What does sloughing refer to in wound healing?
Sloughing refers to the shedding or casting off of dead tissue from a wound, which is often yellow or white and can be stringy or thick.
p.16
Phases of Wound Healing
What is epithelialization?
The process of reforming the superficial epithelial surface of the skin.
p.16
Phases of Wound Healing
What is one of the key functions re-established by epithelialization?
Barrier functions of the skin.
p.31
Wound Assessment Methodologies
Why is it important to assess the entire patient as a whole in wound assessment?
To ensure comprehensive care and address all factors that may affect wound healing.
What should be identified as part of the underlying cause in wound assessment?
The underlying aetiology.
What are the internal causes of wounds?
Vascular, Arterial, Venous, Pressure, Neuropathy, Infective, Malignant, Diabetic.
p.12
Methods of Wound Closure
What type of tissue fills up the space in a wound healing by secondary intention?
Granulation tissue (肉芽組織).
p.62
Management of Chronic Wounds
What are some surrounding skin conditions that can affect wound healing?
Erythema, inflammation, cellulitis, blistering, maceration, and close proximity to the perineum opening.
p.49
Management of Chronic Wounds
What are some risk factors that need to be modified in the management of Stage 1 and 2 pressure ulcers?
Arterial issues and infections.
p.2
Pathophysiology of Pressure Ulcers
What is the pathophysiology of pressure ulcers?
Pressure ulcers develop due to prolonged pressure on the skin, leading to ischemia, tissue damage, and necrosis.
p.29
Importance of Nutritional and Psychosocial Assessment in Wound Care
Why does diabetes contribute to poor wound healing?
Diabetes can cause vascular insufficiency and impair the immune response, leading to slower wound healing.
p.30
Wound Assessment Methodologies
Why is it important to assess the wound bed?
Assessing the wound bed is important to identify the type of tissue present, such as necrotic, granulating, or epithelializing tissue, which guides treatment decisions.
p.30
Wound Assessment Methodologies
What is the significance of assessing the periwound skin?
Assessing the periwound skin is significant to identify signs of maceration, erythema, or infection, which can impact wound healing.
p.61
Wound Assessment Methodologies
Are all chronic wounds colonized with organisms?
Yes, all chronic wounds will be colonized with organisms.
p.61
Management of Chronic Wounds
Do positive culture results without evidence of infection require antibiotics?
No, positive culture results without evidence of infection do not require antibiotics.
p.42
Staging of Pressure Injuries
What is the characteristic of a Stage 3 pressure injury?
Full thickness skin loss.
p.28
Pathophysiology of Pressure Ulcers
What factors can shorten the duration for tissue damage reversibility?
Heavy patient and impaired wound healing power.
p.54
Wound Assessment Methodologies
What is moulding and area measurement in wound assessment?
It is a method used to measure the wound area by creating a mold of the wound.
p.58
Wound Assessment Methodologies
What is exudate in the context of wound care?
Exudate refers to the fluid that leaks out of a wound.
p.50
Wound Assessment Methodologies
What is a limitation of tape measurement in wound assessment?
It fails to account for irregular and undermined wounds.
p.31
Wound Assessment Methodologies
What are the key components of a complete history and physical examination in wound assessment?
Identification of aetiology, co-morbid conditions, and overall patient health.
p.12
Methods of Wound Closure
What is an example of a wound that heals by secondary intention?
A skin abscess after incision and drainage.
p.63
Wound Assessment Methodologies
What status is checked to determine if a wound is infected?
Septic or infective status.
p.9
Phases of Wound Healing
What happens during the remodeling phase of wound healing?
Collagen is remodeled and realigned along tension lines, and cells that are no longer needed are removed by apoptosis.
p.49
Management of Chronic Wounds
How can patient optimization be achieved in the management of Stage 1 and 2 pressure ulcers?
Through proper nutrition and mobilization.
p.2
Phases of Wound Healing
What are the main phases of wound healing?
The main phases of wound healing are hemostasis, inflammation, proliferation, and remodeling.
p.2
Staging of Pressure Injuries
Why is accurate staging of wounds important for management?
Accurate staging of wounds is important for determining the appropriate treatment plan and monitoring the healing process.
p.30
Wound Assessment Methodologies
What does the acronym 'TIME' stand for in wound assessment?
The acronym 'TIME' stands for Tissue management, Infection or inflammation, Moisture balance, and Edge of wound.
p.30
Wound Assessment Methodologies
Why is it important to assess the wound edges?
Assessing the wound edges is important to determine if they are advancing, undermined, or rolled, which can affect healing.
p.20
Phases of Wound Healing
What is the tensile strength of a healing wound compared to normal skin?
0% tensile strength of normal skin.
p.54
Wound Assessment Methodologies
What is the purpose of alternative methods in wound assessment?
To provide more accurate documentation, mainly used for research purposes.
p.57
Wound Assessment Methodologies
What does the odour of exudate indicate in wound assessment?
The odour can indicate the presence of infection or necrotic tissue.
p.41
Staging of Pressure Injuries
What are the benefits of using a staging system in wound assessment?
It improves communication and management of wounds.
p.50
Wound Assessment Methodologies
Why is tape measurement a popular method for wound assessment?
It is simple and common practice.
p.6
Pathophysiology of Pressure Ulcers
What is a necrotic base in the context of pressure ulcers?
A necrotic base refers to dead tissue that is often found at the base of a pressure ulcer.
p.16
Phases of Wound Healing
How does epithelialization help protect against bacteria?
By re-establishing the barrier functions of the skin.
p.31
Wound Assessment Methodologies
What is the purpose of pain assessment in wound care?
To manage pain effectively and improve patient comfort and healing outcomes.
p.62
Management of Chronic Wounds
How do surrounding skin conditions affect wound healing?
They affect wound healing, progression, ease of dressing application, and contamination.
p.47
Staging of Pressure Injuries
What might be revealed if slough or eschar is removed from an unstageable pressure injury?
A Stage 3 or Stage 4 pressure injury.
p.9
Importance of Nutritional and Psychosocial Assessment in Wound Care
How does psychosocial assessment impact wound healing?
Psychosocial factors such as stress, depression, and social support can influence the body's ability to heal wounds effectively.
p.62
Management of Chronic Wounds
Why is the close proximity to the perineum opening a concern for wound healing?
It increases the risk of contamination and infection, complicating wound healing.
p.49
Management of Chronic Wounds
What surgical procedures are involved in the management of Stage 3 and 4 pressure ulcers?
Surgical debridement and flap operation.
p.21
Pathophysiology of Pressure Ulcers
What is a pressure ulcer?
A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear.
p.21
Importance of Nutritional and Psychosocial Assessment in Wound Care
Why is nutritional assessment important in the management of pressure ulcers?
Adequate nutrition is essential for wound healing and preventing the development of pressure ulcers.
p.44
Staging of Pressure Injuries
Are granulation tissue, slough, and eschar present in a Stage 2 pressure injury?
No, granulation tissue, slough, and eschar are not present.
p.20
Phases of Wound Healing
What is the relationship between collagen content and tensile strength in wound healing?
As collagen content increases and reorganizes, tensile strength of the wound also increases.
p.16
Phases of Wound Healing
How does epithelialization prevent fluid loss?
By re-establishing the barrier functions of the skin.
p.63
Staging of Pressure Injuries
What does staging of tissue depth involvement refer to in wound assessment?
The depth and extent of tissue damage.
What are the types of vascular wounds?
Arterial and Venous wounds.
p.47
Staging of Pressure Injuries
What is an unstageable pressure injury?
An injury where the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar.
p.49
Management of Chronic Wounds
What methods are used for pressure relief in Stage 1 and 2 pressure ulcers?
Frequent turning, mattress adjustments, and padding.
p.49
Management of Chronic Wounds
What type of debridement is recommended for Stage 1 and 2 pressure ulcers?
Non-surgical debridement.
p.2
Pathophysiology of Pressure Ulcers
How can pressure ulcers be prevented?
Pressure ulcers can be prevented by regularly repositioning patients, using pressure-relieving devices, and maintaining good skin hygiene.
p.21
Pathophysiology of Pressure Ulcers
What are common sites for pressure ulcers?
Common sites include the sacrum, heels, elbows, hips, and the back of the head.
p.6
Pathophysiology of Pressure Ulcers
What are common areas where pressure ulcers can develop?
Common areas include the lateral malleolus, heel, and sacral region.
p.50
Wound Assessment Methodologies
What is one benefit of using tape measurement for wound assessment?
It is good for monitoring the progress of healing.
p.22
Pathophysiology of Pressure Ulcers
What causes a pressure ulcer?
Intense and/or prolonged pressure or pressure in combination with shear.
What are the external causes of wounds?
Traumatic, Iatrogenic, Surgery, Burn, Chemical, Thermal, Electrical.
p.12
Methods of Wound Closure
What type of wounds usually heal by secondary intention?
Chronic wounds with tissue loss and separated edges.
p.32
Wound Assessment Methodologies
What does the 'Site' refer to in wound assessment?
The location of the wound on the body.
p.47
Staging of Pressure Injuries
What should not be done to stable eschar on the heel or ischemic limb?
It should not be softened or removed.
p.32
Wound Assessment Methodologies
What are 'Specific features' in the context of wound assessment?
Unique characteristics of the wound such as undermining, tunneling, or presence of foreign bodies.
p.29
Pathophysiology of Pressure Ulcers
Why are individuals with quadriplegia, hemiplegia, or paraplegia at high risk for pressure injuries?
Because they are often unable to turn themselves.
p.30
Wound Assessment Methodologies
What is the first step in wound assessment?
The first step in wound assessment is taking a thorough patient history.
p.30
Wound Assessment Methodologies
What role does exudate play in wound assessment?
Exudate is assessed for its amount, color, and consistency, as it can indicate the presence of infection or the stage of healing.
p.54
Wound Assessment Methodologies
Why are alternative methods mainly used in wound assessment?
They are mainly used for research purposes that require more accurate documentation.
p.58
Wound Assessment Methodologies
Why is the assessment of exudate important in wound management?
It guides the selection of dressing materials and the frequency of dressing changes.
p.31
Importance of Nutritional and Psychosocial Assessment in Wound Care
Why is nutritional assessment important in wound care?
Proper nutrition is essential for wound healing and overall patient health.
p.9
Phases of Wound Healing
What occurs during the inflammatory phase of wound healing?
Hemostasis and inflammation, where blood vessels constrict and clotting occurs, followed by the release of inflammatory mediators.
p.31
Importance of Nutritional and Psychosocial Assessment in Wound Care
What role does psychosocial assessment play in wound care?
It helps address emotional and social factors that may impact wound healing.
p.13
Phases of Wound Healing
傷口癒合的五個階段是什麼？
1. 止血 2. 炎症反應 3. 細胞遷移和增殖 4. 蛋白質合成和傷口收縮 5. 重塑
p.63
Wound Assessment Methodologies
What should be assessed regarding the skin around the wound?
Surrounding skin conditions.
p.32
Staging of Pressure Injuries
What does 'Staging/grading' involve in wound assessment?
Classifying the wound based on its severity and depth.
p.29
Pathophysiology of Pressure Ulcers
Which groups are at high risk for pressure injuries due to inability to turn?
Quadriplegic, hemiplegic, paraplegic, individuals with fractured limbs, and those in intensive care or post-operation.
p.2
Staging of Pressure Injuries
What are the stages of pressure injuries?
Pressure injuries are staged from Stage 1 (non-blanchable erythema) to Stage 4 (full-thickness skin and tissue loss), with additional categories for unstageable and deep tissue injuries.
p.21
Pathophysiology of Pressure Ulcers
What are the primary risk factors for developing pressure ulcers?
Primary risk factors include immobility, poor nutrition, moisture, and decreased sensory perception.
p.58
Wound Assessment Methodologies
What type of dressing frequency is recommended for a wound with heavy exudate?
Three or more dressing changes per day are recommended for heavy exudate.
p.32
Wound Assessment Methodologies
What are the 5 'S' in wound assessment and documentation?
Site, Size, Surrounding skin, Staging/grading, Specific features.
p.31
Wound Assessment Methodologies
Why is accurate wound assessment and documentation crucial?
It ensures proper treatment, monitoring, and communication among healthcare providers.
p.49
Management of Chronic Wounds
What is the primary approach for managing Stage 1 and 2 pressure ulcers?
Conservative management, including pressure relief, risk factor modification, and optimization of the patient.
p.9
Importance of Nutritional and Psychosocial Assessment in Wound Care
Why is nutritional assessment important in wound care?
Proper nutrition is essential for providing the necessary building blocks for tissue repair and immune function.
p.62
Management of Chronic Wounds
What is maceration and how does it impact wound care?
Maceration is the softening and breaking down of skin due to prolonged exposure to moisture, which can complicate wound healing.
p.32
Wound Assessment Methodologies
What are 'Exudates' in wound assessment?
The type and amount of fluid produced by the wound, such as serous, purulent, or sanguineous.
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Importance of Nutritional and Psychosocial Assessment in Wound Care
How does organ failure affect wound healing?
Organ failure can impair the body's ability to heal wounds effectively.
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Wound Assessment Methodologies
Why is it important to assess the location of a wound?
Assessing the location of a wound is important because it can influence the type of treatment and healing process.
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Pathophysiology of Pressure Ulcers
What role does moisture play in the development of pressure ulcers?
Excess moisture from sweat, urine, or feces can weaken the skin and make it more susceptible to pressure ulcers.
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Wound Assessment Methodologies
What methodologies are used for wound assessment?
Wound assessment methodologies include visual inspection, measurement of wound size and depth, assessment of exudate, and evaluation of surrounding skin.
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Wound Assessment Methodologies
How can the size of a wound be measured?
The size of a wound can be measured using a ruler or wound measurement grid to determine its length, width, and depth.
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Pathophysiology of Pressure Ulcers
What is shear and how does it contribute to pressure ulcers?
Shear occurs when the skin moves in one direction and the underlying bone moves in another, causing tissue damage and contributing to the development of pressure ulcers.
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Importance of Nutritional and Psychosocial Assessment in Wound Care
How does vascular insufficiency impact wound healing?
Vascular insufficiency reduces blood flow to the wound, impairing the healing process.
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Management of Chronic Wounds
What is the importance of repositioning in the prevention of pressure ulcers?
Repositioning helps to relieve pressure on vulnerable areas, thereby preventing the development of pressure ulcers.
