LEC 2: Wound Care Continued

Question 1

What are the four steps to treating a chronic wound?

Answer 1

• Identify and control the underlying causes
• Support patient centred concerns
• Optimize local wound care; providing an environment to heal
• Provide organizational support

Question 2

What is the function of the Braden Scale?

Answer 2

Helps to identifie patients that are at risk for pressure ulcers

Question 3

What are the six characteristics used to predicting pressure ulcers?

Answer 3

1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction/ shear

Question 4

Braden Scale: Sensory Perception

Answer 4

Ability to respond meaningfully to pressure-related discomfort

Question 5

Braden Scale: Moisture

Answer 5

Degree to which skin is exposed to moisture

Question 6

Braden Scale: Activity

Answer 6

Degree of physical activity

Question 7

Breden Scale: Mobility

Answer 7

Ability to change and control body position

Question 8

Braden Scale: Nutrition

Answer 8

Usual food intake pattern

Question 9

When should a Braden Scale assessment be done on a patient in acute care?

Answer 9

Every 24 hours in acute care

Question 10

How does the Braden Scale work?

Answer 10

The total score ranges from 6 to 23, and a lower total score indicates a higher risk of pressure ulcer development

Question 11

What are the three pressure-related factors that contribute to pressure ulcer development?

Answer 11

• Pressure intensity
• Pressure duration
• Tissue tolerance

Question 12

Suspected Deep Tissue Injury

Answer 12

Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear or both. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue

Question 13

What are the five guidlines for staging pressure ulcers?

Answer 13

• Stage I
• Stage II
• Stage III
• Stave IV
• Unstageable

Question 14

Pressure Injury: Stage I

Answer 14

• Intact skin with nonblanchable redness of a localized area usually over a bony prominence
• Epidermis and dermis are still in-tacked
• When you put pressure on pressure injury, it does not turn white

Question 15

Pressure Injury: Stage II

Answer 15

• Partial thickness loss of dermis
• Looks like shallow ulcer
• Has a red/pink wound bed
• Could be intact or open blister

Question 16

Pressure Injury: Stage III

Answer 16

• Full thickness tissue loss
• Subcutaneous fat may be visible
• Bone, tendon, muscle not visible
• May include undermining and tunnelling
• Possible odour and drainage

Question 17

Pressure Injury: Stage IV

Answer 17

• Fill thickness tissue loss
• Exposed bone , tendon, or muscle
• Slough or eschar may be present
• Often undermining and tunnelling
• Possible odour and drainage

Question 18

Pressure Injury: Unstageable

Answer 18

• Full thickness loss
• Base of ulcer covered by slough or eschar
• Extent of tissue damage can’t be confirmed

Question 19

Slough

Answer 19

Decaying tissue/ collagen, looks yellow

Question 20

Eschar

Answer 20

Dead tissue, looks black/dark

Question 21

Best Practice Guidelines for Interdisciplinary Management

Answer 21

• Wound cleansing
• Debridement of healable wound
• Moisture balance
• Elimination of dead space; packing
• Thermal insulation; good circulation
• Protection of periwound skin

Question 22

Why do we pack a wound?

Answer 22

To eliminate dead space, which allows the wound to heal from bottom up

Question 23

What acronym is used for complex wound assessment?

Answer 23

MEASURE

Question 24

What dose MEASURE stand for?

Answer 24

• Measure
• Exudate
• Appearance of wound base
• Suffering
• Undermining
• Re-evaluate
• Edge

Question 25

MEASURE: Measure

Answer 25

* Length * Width * Depth

Question 26

How do you measure the length of the wound?

Answer 26

The longest dimension of the wound bed (regardless of direction)

Question 27

How do you measure the width of the wound?

Answer 27

Measured at the widest portion of the wound, perpendicular to the length

Question 28

How do you measure the depth of the wound?

Answer 28

With a sterile wet, cotton-tip applicator, measure the greatest distance 90 degrees from the skin surface to the base of the wound

Question 29

MEASURE: Exudate

Answer 29

* Amount and type * Is there an odour

Question 30

MEASURE: Appearance of Wound Base

Answer 30

Estimate percentage of each tissue type * Black wound * Yellow wound * Pink wound

Question 31

Black Wound Base

Answer 31

Devitalized tissue May be grey, brown or black Necrosis can by moist or dry

Question 32

Yellow Wound Base

Answer 32

Decaying collagen (slough) of fibrin

Question 33

Pink Wound Base

Answer 33

* Moist granulation tissue and indicates profiling wounds * May be shades of pink or red * Pink indicated new epithelialization \*What we want the wound to look like

Question 34

MEASURE: Suffering

Answer 34

What is the patient's pain level

Question 35

MEASUR: Undermining

Answer 35

Evaluate the undermining and tunneling of the wound

Question 36

Undermining

Answer 36

Tissue destruction extending under intact skin along the wound margin

Question 37

Tunneling

Answer 37

(sinus tract) course or path of tissue destruction occurring in any direction from the wound bed

Question 38

MEASURE: Re-Evaluate

Answer 38

All wound should be reassessed regularly * Done every time you change the dressing

Question 39

MEASURE: Edge

Answer 39

Appearance of wound edge and surrounding (periwound) skin

Question 40

When talking about wounds, how do we indicate the direction of tunneling and undermining?

Answer 40

When talking about wound use a clockwise direction