NURS 262 EXAM 2 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS GRADED A++
intentional wounds
trauma that occurs during therapy
ex) surgery or venipuncture
unintentional wounds
accidental traume
closed wound
tissue trauma w out break in skin (fracture)
open wound
skinor mucous membrane open
incision
sharp intrament (knife or scapel)
contusion
blow from blunt instrument
abrasion
surface scrape, either intentional or unintentional
puncture
penetration by sharp instrument
laceration
tissues are torn apart
,penetrating
penetration of skin and underlying tissue (bullet, metal fragment)
clean wound
uninfected wounds w minimal inflammation, gastrointestinal, genital, and urinary tracts
are not entered.
=primarily closed wounds.
clean-contaminated wounds
surgical wounds where the gastrointestinal, genital, or urinary tract has been entered.
- show no evidence of infection.
contaminated wounds
open, accidental, and surgical wounds involving a major break in sterile technique or
spillage from the gastrointestinal tract
- show evidence of inflammation.
dirt/infected wounds
wounds with evidence of a clinical infection, such as purulent drainage or necrosis.
partial thickness
Confined to superficial skin layers
-damage does not penetrate below the dermis and may be limited to only the epidermal
layers
full thickness
Tissue damage involving total loss of the epidermis, dermis and extending into the
subcutaneous tissue, possibly into muscle or bone.
granulation tissue
,Pink/red moist tissue composed of new blood vessels and connective tissues,
fibroblasts and inflammatory cells, which fills an open wound when it starts to heal
-usually with a deep pink or red color with an irregular granular surface
slough
Soft, moist avascular tissue; may be white, yellow, tan or grey.
-May be loose or firmly adherent.
eschar
Black or brown necrotic devitalized tissue.
-Can be loose or firmly adherent, soft, hard, boggy, dry or wet
exudate
Accumulation of fluid within the wound
serous
thin clear or yellow tinged.
-Contains white blood sells, sugars and proteins.
Sanguineous
bright red; large amounts of red blood cells
Serosanguineous
thin pink tinged exudate
purulent
thicker than serous exudate because of the presence of pus, which consists of
leukocytes, liquefied dead tissue debris, and dead and living bacteria.
- Purulent exudates vary in color.
-Some acquire tinges of blue, green, or yellow, depending on the causative organisms
, Sanguinopurulent
Pink cloudy exudate
-Contains pus and blood
layers of skin
epidermis, dermis, hypodermis
epidermis
• Five layers
• Avascular
• Rapid cell regeneration
-changes in elderly found in this layer
dermis
• Papillary dermis
• Reticular dermis
• Vascular
hypodermis
Subcutaneous
stage 1 pressure injury
non-blanchable erythema of intact skin
-changes in sensation, temperature, or firmness may precede visual changes
risk factors for pressure injuries
• Advanced age - Age> 70
• Compromised mobility
• Compromised sensory perception - diminished sensation
COMPLETE SOLUTIONS GRADED A++
intentional wounds
trauma that occurs during therapy
ex) surgery or venipuncture
unintentional wounds
accidental traume
closed wound
tissue trauma w out break in skin (fracture)
open wound
skinor mucous membrane open
incision
sharp intrament (knife or scapel)
contusion
blow from blunt instrument
abrasion
surface scrape, either intentional or unintentional
puncture
penetration by sharp instrument
laceration
tissues are torn apart
,penetrating
penetration of skin and underlying tissue (bullet, metal fragment)
clean wound
uninfected wounds w minimal inflammation, gastrointestinal, genital, and urinary tracts
are not entered.
=primarily closed wounds.
clean-contaminated wounds
surgical wounds where the gastrointestinal, genital, or urinary tract has been entered.
- show no evidence of infection.
contaminated wounds
open, accidental, and surgical wounds involving a major break in sterile technique or
spillage from the gastrointestinal tract
- show evidence of inflammation.
dirt/infected wounds
wounds with evidence of a clinical infection, such as purulent drainage or necrosis.
partial thickness
Confined to superficial skin layers
-damage does not penetrate below the dermis and may be limited to only the epidermal
layers
full thickness
Tissue damage involving total loss of the epidermis, dermis and extending into the
subcutaneous tissue, possibly into muscle or bone.
granulation tissue
,Pink/red moist tissue composed of new blood vessels and connective tissues,
fibroblasts and inflammatory cells, which fills an open wound when it starts to heal
-usually with a deep pink or red color with an irregular granular surface
slough
Soft, moist avascular tissue; may be white, yellow, tan or grey.
-May be loose or firmly adherent.
eschar
Black or brown necrotic devitalized tissue.
-Can be loose or firmly adherent, soft, hard, boggy, dry or wet
exudate
Accumulation of fluid within the wound
serous
thin clear or yellow tinged.
-Contains white blood sells, sugars and proteins.
Sanguineous
bright red; large amounts of red blood cells
Serosanguineous
thin pink tinged exudate
purulent
thicker than serous exudate because of the presence of pus, which consists of
leukocytes, liquefied dead tissue debris, and dead and living bacteria.
- Purulent exudates vary in color.
-Some acquire tinges of blue, green, or yellow, depending on the causative organisms
, Sanguinopurulent
Pink cloudy exudate
-Contains pus and blood
layers of skin
epidermis, dermis, hypodermis
epidermis
• Five layers
• Avascular
• Rapid cell regeneration
-changes in elderly found in this layer
dermis
• Papillary dermis
• Reticular dermis
• Vascular
hypodermis
Subcutaneous
stage 1 pressure injury
non-blanchable erythema of intact skin
-changes in sensation, temperature, or firmness may precede visual changes
risk factors for pressure injuries
• Advanced age - Age> 70
• Compromised mobility
• Compromised sensory perception - diminished sensation
