Midterm

Question 1

Drainage

Answer 1

None = 0% of drainage on dressing
Scant/small = 1-25%
Minimal = 25-50%
Moderate = 51-75%
Large = 76-100%
Copious = soaked
***Amount is comparable to the size of the wound!***

Question 2

Drainage (PUSH)

Answer 2

(Pressure Ulcer Scale for Healing)

Scant/small = 3/4

Question 3

Difference between purulent and pus

Answer 3

Purulent = creamy or thick, opaque to yellow
Pus = thick, opaque yellow to green color and FOUL SMELLING

Question 4

Confusing periwound terms

Answer 4

Excoriated = raw appearance (i.e. diaper rash)
Macerated = white & pruney
Indurated = fluid that is firm
Fluctuant = fluid that is loose & boggy

Question 5

Infection terms

Answer 5

Sterile
Contaminated = presence of replicating organism in wound
Colonized = presence of replicating organism in the wound WITHOUT host immune response
Critically colonized
Infected = presence of replicating organism in the wound WITH host immune response

Question 6

TCC

Answer 6

Total contact cast (gold standard):
Plantar foot ulcers
NO infection
Good blood flow
Good standard wound care
Controlled drainage over several days
Good cognition
Balance deficits (if any) are managed
***7 days (no longer than 14 days)***

Question 7

Common dressings for DFUs

Answer 7

Transparent films, hydrofilms, topical agents, biologicals, hydrofibers, non-adherents, xeroform, antimicrobials, bioengineered tissues

Question 8

Lab values that promote a healing environment

Answer 8

FSBG = 3.0; 17 – problems with wound healing if

Question 9

Chronic venous hypertension

Answer 9

> 90 mmHg

Question 10

Rubor of Dependency

Answer 10

Supine, examine plantar aspect of foot. Elevate leg to 60 degrees for one minute (stop if pain reported):

Pallor observed in 45-60 sec = mild arterial insufficiency
Pallor observed in 30-45 sec = moderate arterial insufficiency
Pallor observed in 25 sec = severe arterial insufficiency

Question 11

Capillary refill

Question 12

Venous refill

Answer 12

Test only valid if patient does NOT have venous insufficiency
Supine, examine dorsal aspect of foot. Elevate leg to 60 degrees for one minute (stop if pain reported). Place leg in dependent position and watch for fill time:

20 seconds (or > 30) = arterial insufficiency

Question 13

Toe-Brachial Index

Answer 13

TcPO2 (Transcutaneous partial pressure of oxygen):

30 mmHg = adequate blood flow for healing to occur
> 40 mmHg = normal

Question 14

Contraindications to intermittent pneumatic compression (and compression in general for that matter)

Answer 14

DVT, ABI

Question 15

6 Stages of Pressure Ulcers

Answer 15

1 = non-blanchable erythema
2 = partial thickness --> epidermis and dermis ONLY
3 = full thickness --> necrosis/damage extending down to but not including the fascia; may include sinus tracts/undermining
4 = full thickness tissue loss --> necrosis/damage to underlying structures; sinus tracts/undermining common
5 = unstageable --> completely covered in slough/eschar and cannot be staged until removed
6 = deep tissue injury

Question 16

Braden Scale

Answer 16

(Score goes from 6-23)

Categories:
Sensory perception, moisture, mobility, activity, friction & shear, nutrition

Score of 18 or lower = at risk
The HIGHER the score the BETTER!

Question 17

Pediatric Risk Assessment

Answer 17

Glamorgan Scale, Neonatal Risk Assessment, Braden-Q (21 days - 8 years)

Question 18

Bed bound repositioning

Answer 18

Every 2 hours

Question 19

Chair bound repositioning

Answer 19

Every hour; Shift weight every 15 minutes

Question 20

Pre-albumin and serum albumin levels

Answer 20

Pre-albumin is 16-40 mg/dL, serum albumin is 3.5-5.5 mg/dL

Question 21

Categories of support surfaces

Answer 21

Reactive support surface, Active support surface, Integrated bed system, non-powered, powered, overlay, mattress

Question 22

The 5 I’s

Answer 22

Immobility, inactivity, incontinence, improper nutrition, impaired mental status or sensation

Question 23

When to check for PrUs

Answer 23

Acute: on admission, every 24 hours
Long-term care: on admission, weekly for 4 weeks, then quarterly
Home care: on admission, at every home visit