Integ PT Exam Wound Exam - Class 3

Question 1

pt protection

Answer 1

prevention of nosocomial infections

antimicrobial prophylaxis prior to surgery

hand washing

Question 2

antimicrobial prophylaxis prior to surgery

Answer 2

reducing intestinal flora before surgery

preventing bacteria access to the wound

cleaning the wound by mechanical methods

administering antibiotics prophylactically

Question 3

controlling wound infection –> pt

Answer 3

boost immune response

glucose control

IV antibiotics

nutrition

hydration

hyperbaric therapy

Question 4

controlling wound infection –> wound

Answer 4

debride necrotic tissues

remove infected foreign objects

absorb heavy exudates

irrigation and debridement

Question 5

controlling wound infection –> dressings

Answer 5

non-occlusive

absorptive

topical antimicrobials

silver based

honey based

Question 6

pt eval

Answer 6

history

current health status

nutrition and hydration status

mental health

fxnal status

strength and ROM

Question 7

pt eval –> subjective exam

Answer 7

pains behavior

pain rating scales

Question 8

pains behavior

Answer 8

positional

time

nature

Question 9

wound exam –> objective

Answer 9

location (by anatomical position)

size

depth

depth of wound

Question 10

size of the wound

Answer 10

linear measurement LxW in cm

greatest length - greatest width

clock method

Question 11

depth

Answer 11

tunneling or undermining

full/partial thickness

pressure staging system

Question 12

tunneling

Answer 12

has a definitive end

angular

Question 13

undermining

Answer 13

no end

goes into something else

Question 14

depth of wound

Answer 14

classification with staging system

classification by thickness

Question 15

classification with staging system

Answer 15

for pressure ulcers only

Question 16

classification by thickness

Answer 16

partial

full

Question 17

stages of classification by staging system

Answer 17

suspected deep tissue injury

stage 1-4

unstageable

Question 18

suspected deep tissue injury

Answer 18

purple or maroon localized area of discolored intact skin

blood filled blister d/t damage of underlying soft tissue from pressure and/or shear

Question 19

area may be preceded by –> suspected deep tissue injury

Answer 19

tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue

Question 20

stage 1 –> appearance

Answer 20

non-blanchable erythema of intact skin

usually over a bony prominence

Question 21

stage 1 –> darker skin

Answer 21

non-blanchable redness may not be visible

presents with discoloration, warmth or coolness, edema, induration and pain

Question 22

stage 1 –> ________ of skin ulceration

Answer 22

heralding lesion

Question 23

stage 2

Answer 23

partial thickness skin loss

involving epidermis and or dermis

does not fully go through dermis

Question 24

stage 2 –> clinically presents

Answer 24

blister (intact or open/ruptured serum filled), abrasion, shallow crater

Question 25

stage 2 --> wound bed

Answer 25

red/pink moist

Question 26

stage 2 --> differentiated from

Answer 26

skin tears tape burns dermatitis maceration or excoriations

Question 27

stage 3

Answer 27

full thickness skill loss involving damage to subcutaneous tissue may extend to fascia but NOT THROUGH IT

Question 28

stage 3 may have

Answer 28

undermining or tunneling

Question 29

stage 4

Answer 29

full thickness skin loss w/ extensive tissue destruction

Question 30

stage 4 damage

Answer 30

extends to muscle, bone, tendons and joint capsule

Question 31

unstageable

Answer 31

full thickness tissue loss in which the base of the ulcer is covered by slough +/or eschar in the wound bed

Question 32

slough

Answer 32

yellow tan grey green brown

Question 33

eschar

Answer 33

tan brown black

Question 34

wound edges

Answer 34

distinct v. indistinct attached v. unattached

Question 35

are the wound edges

Answer 35

hyperkeratotic ischemic macerated

Question 36

tissue type

Answer 36

is it bone, tendon, fascia, muscle, fatty tissue exposed grafts or vessels necrotic and granulation tissue

Question 37

necrotic tissue

Answer 37

choose most predominant type quantify in percentages

Question 38

granulation tissue

Answer 38

beefy red pink or dusky hyper granulating

Question 39

epithelialization

Answer 39

& of wound margin

Question 40

exudate

Answer 40

type and amount

Question 41

type of exudate

Answer 41

serous sanguineous serosanguinous purulent foul purulent

Question 42

amount of exudate

Answer 42

none scant minimal moderate heavy

Question 43

wound infection

Answer 43

red granulation tissue that has ceased for a period of time to progress towards contraction and epithelialization hyper granulation tissue

Question 44

wound culturing

Answer 44

needle aspirations/biopsies swab culturing

Question 45

peri wound tissue

Answer 45

assess color temp moisture

Question 46

tissue edema

Answer 46

asses within 4.0 cm of wound edge pitting v. non-pitting presence of induration

Question 47

edema assessment

Answer 47

part of the wound examination