NUR 155
EXAM 3 STUDY GUIDE
Foundations of Nursing
Galen College of Nursing
, EXAM 3 REVIEW
Chapter 36 – Wounds
Factors Affecting Skin Integrity
o Genetics and heredity
o Age
o Chronic illness and their treatments
o Medications - antibiotics, decreased immune system drugs, steroids (increase BP), and
people with a sugary base, like diabetics, tend to have an increased risk of infection
o Poor nutrition
Types of Wounds
o Wounds are either Intentional or unintentional
Intentional
Trauma that occurs during therapy
Example: operations or venipunctures
Unintentional
Accidental
Example: a person may fracture an arm in an automobile collision
o Classifying wounds by Depth
Partial thickness: confined to the skin, that is, the dermis and epidermis; heal by
regeneration
Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly
muscle and bone; require connective tissue repair
o Wounds contamination
Clean wounds: infected wounds in which there is minimal inflammation and the
respiratory, gastrointestinal, genital and urinary tracts are not entered. Clean wounds
are primarily closed wounds.
Clean-contaminated wounds: surgical wounds in which the respiratory,
gastrointestinal, genital or urinary tract has been entered. Such wounds show no
evidence of inflammation.
Contaminated wounds: include open, fresh, accidental wounds and surgical wounds
involving a major break in sterile technique or a large amount of spillage from the
gastrointestinal tract. Contaminated wounds show evidence of inflammation.
Dirty or infected wounds: include wounds containing dead tissue and wounds with
evidence of a clinical infection, such as purulent drainage.
o Types of Wounds
Incision
Cause: sharp instrument (ex: knife/scalpel) – surgical/cut
Open wound; deep or shallow; once the edges have been sealed together as
a part of treatment or healing, the incision becomes a closed wound
, Contusion
Cause: blow from a blunt instrument – baseball bat
Closed wound; skin has ecchymosis (bruised)
because of damaged blood vessels
Abrasion
Cause: surface scrape, either intentional (dermal abrasion to remove
pockmarks) or unintentional (scraped knee from a fall)
Open wound involving the skin
Puncture
Cause: penetration of the skin and often
the underlying tissues by a sharp
instrument, either intentional or
unintentional (goes in & comes out – traps
bacteria)
Open wound
Laceration
Cause: tissues torn apart, often from accidents
(ex: machinery)
Open wound; edges are often jagged
Penetrating Wound
Penetration of the skin and the underlying tissues,
usually unintentional (ex: from a bullet or metal fragments)
Open wound
o Different ways to close a wound
Before closing a wound make sure its clean
Sutures- 7-10 days (jagged laceration)
When taking off, hold knot with
tweezers, cut one side closest to
the skin and pull longest side –
this prevents the dirty suture
from being pulled through skin
(avoids contamination).
Used for deep tissue wounds
Absorbent sutures are used deep
in the tissues. They dissolve, they
are not removed.
Nonabsorbent sutures
(superficial) require removal,
often by a nurse.
EXAM 3 STUDY GUIDE
Foundations of Nursing
Galen College of Nursing
, EXAM 3 REVIEW
Chapter 36 – Wounds
Factors Affecting Skin Integrity
o Genetics and heredity
o Age
o Chronic illness and their treatments
o Medications - antibiotics, decreased immune system drugs, steroids (increase BP), and
people with a sugary base, like diabetics, tend to have an increased risk of infection
o Poor nutrition
Types of Wounds
o Wounds are either Intentional or unintentional
Intentional
Trauma that occurs during therapy
Example: operations or venipunctures
Unintentional
Accidental
Example: a person may fracture an arm in an automobile collision
o Classifying wounds by Depth
Partial thickness: confined to the skin, that is, the dermis and epidermis; heal by
regeneration
Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly
muscle and bone; require connective tissue repair
o Wounds contamination
Clean wounds: infected wounds in which there is minimal inflammation and the
respiratory, gastrointestinal, genital and urinary tracts are not entered. Clean wounds
are primarily closed wounds.
Clean-contaminated wounds: surgical wounds in which the respiratory,
gastrointestinal, genital or urinary tract has been entered. Such wounds show no
evidence of inflammation.
Contaminated wounds: include open, fresh, accidental wounds and surgical wounds
involving a major break in sterile technique or a large amount of spillage from the
gastrointestinal tract. Contaminated wounds show evidence of inflammation.
Dirty or infected wounds: include wounds containing dead tissue and wounds with
evidence of a clinical infection, such as purulent drainage.
o Types of Wounds
Incision
Cause: sharp instrument (ex: knife/scalpel) – surgical/cut
Open wound; deep or shallow; once the edges have been sealed together as
a part of treatment or healing, the incision becomes a closed wound
, Contusion
Cause: blow from a blunt instrument – baseball bat
Closed wound; skin has ecchymosis (bruised)
because of damaged blood vessels
Abrasion
Cause: surface scrape, either intentional (dermal abrasion to remove
pockmarks) or unintentional (scraped knee from a fall)
Open wound involving the skin
Puncture
Cause: penetration of the skin and often
the underlying tissues by a sharp
instrument, either intentional or
unintentional (goes in & comes out – traps
bacteria)
Open wound
Laceration
Cause: tissues torn apart, often from accidents
(ex: machinery)
Open wound; edges are often jagged
Penetrating Wound
Penetration of the skin and the underlying tissues,
usually unintentional (ex: from a bullet or metal fragments)
Open wound
o Different ways to close a wound
Before closing a wound make sure its clean
Sutures- 7-10 days (jagged laceration)
When taking off, hold knot with
tweezers, cut one side closest to
the skin and pull longest side –
this prevents the dirty suture
from being pulled through skin
(avoids contamination).
Used for deep tissue wounds
Absorbent sutures are used deep
in the tissues. They dissolve, they
are not removed.
Nonabsorbent sutures
(superficial) require removal,
often by a nurse.
