Integumentary

Question 1

Transudate

Answer 1

•Color:
- clear

•Thickness
- thin, watery

Question 2

Serosanginous

Answer 2

•Color:
- clear or a tinge or red/brown

•Thickness:
- thin, watery

Question 3

Exudate

Answer 3

• Color:
- creamy and yellowish

• Thickness:
- moderate to very thick, expected with autolytic debridement

Question 4

Pus

Answer 4

• Color:
- yellow, brown

• Thickness:
- moderate to very thick

Question 5

Infected pus

Answer 5

• Color:
- hues of yellow, blue, green

• Thickness:
- thick, usually indicates infection (but may be normal as WBC macrophage necrotic cells and turn them into slough); drainage can be foul and yet the wound may not be infected

Question 6

Stage I PI

Answer 6

Non-blanchable erythema of intact skin
•intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin.
•presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration (as these colors may indicate a deep tissue PI)

Question 7

Stage II PI

Answer 7

Partial-thickness skin loss with exposed dermis:
•partial thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. •Adipose (fat) is not visible and deeper tissues are not visible.
•Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.
•This stage should not be used to describe moisture associated skin damage (MASD) including icontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions)

Question 8

Stage III PI

Answer 8

Full thickness skin loss:
•full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible.
•The depth of the tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.
•Undermining and tunneling may occur.
•Fascia, muscle. tendon, ligament, cartilage and/or bone are not exposed.
•If slough or eschar obscures the extent of tissue loss this is an unstageable PI

Question 9

Stage IV PI

Answer 9

Full thickness skin and tissue loss:
•full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.
• Slough and or eschar may be visible
•Epibole (rolled edges), undermining and/or tunneling can often occur.
•Depth varies by anatomical location.
•If slough or eschar obscures the extent of tissue loss this is an unstageable PI

Question 10

Unstageable PI

Answer 10

• full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
• If slough or eschar is removed, a Stage 3 or 4 PI will be revealed.
• Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance- a tense area of skin with a wave-like or boggy feeling upon palpation; this is the pus which has accumulated beneath the epidermis) on the heel or ischemic limb should not be softened or removed

Question 11

Deep tissue PI (DTP)

Answer 11

Persistent Non-blanchable deep red, maroon, or purple discoloration
•intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal seperation revealing a dark wound bed or blood filled blister.
•pain and temp change often precede color changes.
• discoloration may appear differently in darkly pigmented skin.
• this injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.
•The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss.
•If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness PI (unstageable, Stage III, or stage IV). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Question 12

Non-selective debridement

Answer 12

• Wet to dry dressings
• Surgical debridement
• Pulsatile lavage with suction (PLWS)
• Whirlpool

Question 13

Wet to dry dressings

Answer 13

• Type of non-selective debridement
• Wet gauze applied to wound bed and allowed to dry on the wound. Removal of the dry dressing pulls away any cellular material that has adhered to the gauze (both healthy and dead tissue). Many studies show negative results, used to be used because it was thought to be cheap but now it is known that this method ends up being more expensive than advanced dressings.

Question 14

surgical debridement

Answer 14

• Type of non-selective debridement
• wide excision, removing viable and nonviable tissue. Provides rapid results when treating life-threatening necrosis, tunneling wounds, and necrotic or infected bones. Usually done in operating room with anesthesia.

Question 15

Pulsatile lavage with suction (PLWS)

Answer 15

• Type of non-selective debridement

* Provides non-selective debridement while cleansing a wound.

Question 16

Whirlpool

Answer 16

• Type of non-selective debridement
• Can be used for mechanical debridement through its feature of water agitation. It can also be used to soften necrotic tissue in preparation for sharp, enzymatic, or autolytic debridement. There are, however, often better methods for prepping wound for debridement.

Question 17

Selective debridement

Answer 17

• Sharp: scalpel, scissors, forceps, hydrosurgery devices, laser
• Chemical or Enzymatic
• Biosurgery: MGT (maggot debridement therapy)

Question 18

Sharp debridement

Answer 18

• Type of selective debridement
• Sharp: scalpel, scissors, forceps, hydrosurgery devices, laser: considered the gold standard of methods for removal of necrotic tissue, sharp debridement is a monor, tissue-sparing procedure that is performed bedside or in a procedure room (within PT scope of practice not PTA)
• contraindicated for vascular wounds with limited blood flow where eschar may serve as a cap or cover for a chronic open wound.
• not appropriate for wounds with tunneling (when the wound bed can’t be seen) or areas with dry gangrene, or patients who don’t clot well.

Question 19

Chemical or enzymatic debridement

Answer 19

• Type of selective debridement
• includes the application of a topical agent containing enzymes that act by dissolving necrotic tissue.
• debridement is selective, patient discomfort is minimal, and application procedures are simple.
• potential development of dermatitis of the intact periwound skin, frequent dressing changes disrupting the wound bed, and the need to crosshatch existing eschar with a scalpel so the enzyme can penetrate the wound.

Question 20

Biosurgery: Maggot debridement therapy (MDT)

Answer 20

• Type of selective debridement
• sterile, newly hatched larvae are placed on chronic wounds and held in place with dressings or biobags for 2 to 5 days before removal.
• shown to decrease risk of infection, remove devitalized tissue, and improve wound healing without side affects in a wide variety of wound types
• recommended for osteomyelitis and deep wound infections that remain unresponsive to conventional approaches.

Question 21

Medical grade honey

Answer 21

• shown to enhance debridement and healing
• available in hydrocolloid, alginate, and liquid categories.
• facilitate autolytic debridement, decrease or eliminate wound odor, prevent biofilm (thin layer of bacteria) formation, and soften necrotic tissue

Question 22

Autolytic debridement

Answer 22

• uses the endogenous enzymes on the wound bed to digest devitalized tissue and promote granulation tissue formation.
• the body’s natural fluids are held in contact with the wound base with a moisture-retentive dressing for 3 to 7 days.
• least expensive and invasive, most selective, painless, and biocompatible
• each pt is examined to determine if this type of debridement is best for the wound

Question 23

Gauze/fiber

Answer 23

• once very popular, but now used mostly as a secondary dressing if the dressing needs to be changed often or if exudate is heavy
• as a primary dressing the gauze leaves contaminating fibers in the wound, is permeable to bacteria, and can adhere to the wound
• impregnated gauze is another option, which has fibers infused with vaseline, intended to prevent the gauze from sticking- used as a primary dressing this choice is minimally absorptive and protective, does not enhance a moist environment and may create a greasy wound bed. One of its more appropriate uses is as a primary dressing over new sutures to prevent them from catching on regular gauze.

Question 24

Transparent films

Answer 24

• made of transparent membrane with an acrylic adhesive layer.
• Transparent films do not allow bacteria or moisture into the wound.
• facilitate a moist wound environment, trapping endogenous fluids in the wound bed to assist with angiogenesis (the development of new blood vessels) (autolytic debridement)
• films assist in protecting skin from shearing, friction, and the contaminating effects of incontinence.
• removal should be done carefully as it could tear the skin
• do not have absorptive qualities so cannot be used with highly exuding wounds
• use for superficial wounds with minimal drainage or as a secondary dressing over foam or gauze.

Question 25

Foam dressing

Answer 25

• highly absorbent pads, sheets, or ropes of polyurethane or polyvinyl alcohol available in many sizes with many features.
• available with or without adhesive backing so they can be used as a primary or secondary dressing.
• highly absorptive but also help to create an occlusive environment for moist wound healing.
• should not be used alone on a dry wound but could serve as a secondary dressing if the primary dressing was a gel product.

Question 26

Hydrogels

Answer 26

• categorized as amphorous, referring to a liquid-like gel, or as sheets, consisting of a thin and flexible sheet of polymer containing at least 90% water.
• both types are used to increase moisture in dry wound beds, soften necrotic tissue, and support autolytic debridement.
• Both have some absorptive qualities and will swell lightly until they are saturated.
• The amphorous gel must be contained in the wound with a secondary dressing.
• The flexible sheets usually require a secondary dressing but are available through some vendors with adhesive tape borders.
• patients usually like the soothing sensation of the hydrogel application

Question 27

Hydrocolloids

Answer 27

• considered the most occlusive of the moisture-retentive dressings, hydrocolloids are also available in less occlusive or semipermeable styles as well.
• As with foams these dressings come in a variety of styles and shapes, including pastes, granules, powder, and sheets.
• typically consist of an absorbent colloidal material combined with a film or foam backing
• Hydrocolloid dressings work best on mild to moderate exudating wounds.
• when wound exudate combines with the colloid polymer, a soft, gelatinous, often yellow, and malodorous mass is formed, make sure everyone involved in patient care (esp pt) is educated on this so that infection is not assumed
• Used successfully as occlusive dressings over infected wounds without growth of existing bacteria
• The dressing of choice to cover and protect larvae during maggot debridement therapy

Question 28

Alginates

Answer 28

• also known as calcium alginate (manufactured using calcium salts of alginic acid from marine algae and kelp)
• Raw material is woven and then converted into flat sheets, roped, or ribbon shapes.
• Alginates absorb 20 to 30 times their own weight, are gentle to apply and remove, and are biocompatible with the wound bed.
• Chemical reaction between the dressing and wound exudate creates a gel substance that helps to maintain a moist wound environment while absorbing excess exudate.
• Because they are permeable, alginates do not provide a barrier against bacteria. This characteristic can make them an effective choice when an infected wound cannot be covered with an occlussive dressing.
• Most alginates currently require a secondary dressing to hold them in place.