Quiz 2 Flashcards
What are some tissue types you may see in a wound bed? Give a description
- Slough - yellow, clumpy
- Granulation - pink/red, wet
- Epithelial - shiny, new pink tissue
- Necrotic (eschar) - black, leathery, firmly adhered to the wound
T or F? A wound with slough tissue is always infected?
False
Which types of exudate are normal? which are abnormal and possibly infected?
Normal:
- Serous (clear/thin)
- Serosanguineous (red/pink/watery)
- Sanguineous (red/thin/watery)
Abnormal/Infection:
- Purulent (yellow/thick)
- Seropurulent (watery/cloudy/yellow)
- Pseudomonas (blue/green)
What are the 3 lines of defense from pathogens?
1.) Surface/skin barrier
2.) Cellular and chemical defenses (immune cells and inflammatory response)
3.) Specific defense (lymphocytes and antibodies)
What are the 4 levels of infection?
1.) Contamination (microbes on the surface… normal)
2.) Colonization (replicating microbes on surface… normal)
3.) Critical colonization (microbes on surface begin to delay wound healing… abnormal)
4.) Infection (replicating microbes invade body tissues and decline wound status… normal)
What does “impregnated” refer to in terms of wound healing?
The process in which substances are embedded within the skin
What are the signs of inflammation?
Redness (erythema), edema, heat, loss of function, pain
What are the signs of infection?
- Exact same as the inflammation signs, but excessive
- Thick, smelly, green/blue, copious (a lot of) exudate
- Decline in wound status despite appropriate care
- Systemic symptoms like fever and nausea
What are some of the primary purposes of wound dressings?
- Protect from injury
- Provide a moist, warm environment (ideal for wound healing)
- Manage drainage
- Gas exchange
Describe the pulse ratings
0: No pulse
1: Thready pulse (barely there)
2: Weak pulse
3: Normal pulse
4: Pounding/racing pulse
Differentiate between undermining and tunneling
Undermining: Destruction of tissue under the wound edges so the wound is actually bigger than what you can see from the surface
Tunneling: A separation of fascial layers under the skin forming a tunnel deep in an area of a wound
What percent decrease in wound surface area within 2-4 weeks signifies good indication
of wound healing
a. 10-20%
b. 20-40%
c. 40-60%
d. 50-70%
b. 20-40%
A micro-organism is multiplying to the extent that it is impairing wound healing and wound bioburden, what level of infection is it at
a. Contamination
b. Colonization
c. Critical colonization
d. Infection
c. Critical colonization
What is a silent infection?
An infection that does not have noticeable symptoms/signs making it tough to detect
Which patient population are susceptible to silent infections?
The immunocompromised and individuals with inadequate perfusion (restricted blood flow)
What is the difference between inflammed tissue and infected tissue?
Inflammed tissue has well defined borders while infected tissue does not
What is the gold standard for diagnosing a wound infection?
Tissue biopsy
A patient needs to get an MRI but has a wound with an antimicrobial silver dressing on, how should they proceed?
Remove the dressing before the MRI (silver is metal and cannot go in an MRI)
A patient has MRSA, should you use standard or universal precautions?
Standard (contact precautions: gown and gloves)
How long is saline good for once it is opened?
24 hours
What type of environment is ideal for wound healing?
Moist and warm environment
Describe the edema scale ratings
1+ : Indentation is barely visible
2+ : Slight indentation with depression, returns to normal within 15 seconds
3+ : Deeper indentation when pressed, returns to normal in 15-30 seconds
4+ Indentations that last longer than 30 seconds
What is undermining?
Area of destruction under wound edges
What is tunneling?
A passageway of tissue destruction under the skin surface (can turn into sinus tract)
What is a sinus tract?
A cavity or channel underlying a wound that allows fluid to drain to the wound surface (greater risk for an infection)
What is an abscess?
A buildup of pus in or on the skin
What is a fistula?
An abnormal opening or passage between two organs or between an organ and surface of the body
List and describe the 6 different exudates
Sanguineous: blood
Serosanguineous: blood/water
Serous: clear thin
Purulent: Yellow, tan, green, thick
Seropurulent: Cloudy yellow tan, thin watery
Pseudomonas: blue/green drainage
What is the “TACO” method to determing a wound’s status
T - Type
A - Amount
C - Color
O - Odor
List the 6 types of exudate and differentiate whether they’re normal or infected
Normal: Serous, Sanguineous, Serosanguineous
Possible infection: Purulent, Seropurulent, Pseudomonas
T or F? Thin exudate is typically normal, thick indicates possible infection
True
What are the 3 types of moisture associated skin damage?
Intertrigo: Inflammation in skin folds related to perspiration, friction, and bacterial/fungal bioburden
Periwound Maceration: Skin breakdown from fluid
IAD: Urine, stool, containment device, secondary cutaneous infection
How long after a scar closes is it able to change/adapt?
As long as the scar is pink and it blanches
How do you measure a wound?
Length x Width
and measure deepest point of wound
What is hemosiderosis?
A rupture of blood vessels around a wound (primarily seen in venous wounds and some pressure ulcers)
What is an ecchymosis?
Discoloration underneath the skin caused by trauma (necrosis can occur if not absorbed in timely manner)
Describe the Arterial Brachial Index (ABI)
Vessel calcification, falsely elevated: >1.1-1.3
Normal: .9 - 1.1
Mild to moderate arterial disease: .7-.9
Moderate arterial disease: .5 - .7
Severe arterial occlusive disease: <.50
What are 4 things to look for in a scar?
- Color
- Hypertrophic
- Keloid
- Hyper-kerototic
What are the 5 circulation tests?
- Rubor of dependency
- Capillary refill test
- Venous refill time
- DVT testing
- Homan’s test
What is a good indicator of wound healing
20-40% decrease in wound surface area within 2-4 weeks
What are some poor indicators of wound healing?
- No decrease in size or signs of improvement within 2 weeks
What are some factors that increase the risk of infection?
- Immunocompromised
- Diabetes
- Steroid use
- Age
- Chronic wounds
- Malnutrition
- Obesity
What are some signs of infection?
- Change in wound drainage
- Edema
- Warmth
- Redness
- Increased pain
- Fever
- Nausea
- WBC elevation
List 5 signs of critical colonization
- Failure to show signs of
healing after 4 weeks (with
proper/appropriate care)
– Increase exudate
– Friable granulation tissue
– Increase or continued
presence of necrotic tissue
– Wound odor
If patient has 3 or more, he/she has critically colonized wound (73% sensitivity, 81% specificity)
Differentiate between inflamed and infected drainage
Inflamed: Proportionate to size of wound, thin consistency, serous or serosanguinous
Infected: Disproportionate to size of wound, thick purulent consistency, may have odor
How does the healing process differ between an inflamed and infected wound?
Inflamed: Follows 3 phases but at a slower rate
Infected: Plateau in healing, decreased granulation tissue (and cobble like)
T or F? you should monitor patient’s with PAD closely due to their increased risk of silent infection
True
What are the two types of fungal infection? describe into further depth
Candida and tinea
- common with long term antibiotic use
- common in individual’s with moist areas of skin (between toes, etc.)
Which topical medications are used for fungal infection?
Nyastin, Oxiconazole Nitrate, Miconazole
Who is at risk for nosocomial (hospital spread) infection? community acquired?
Nosocomial
- Increased age
- Diabetes
- Immunosuppression
- Malnutrition
- Large burns
- Recent surgery
Community Acquired
- Prisons
- Contact sports teams
- Military
- People dx with AIDS
T or F? VRE is commonly seen in surgical wounds and UTIs
True
Examples of antimicrobial therapy includes
- Antibacterial agents
- Antifungal
- Dressing impregnated with antimicrobials
Examples of topical antimicrobial therapy includes
- Bacitracin
- Neomycin
- Triple antibiotic ointment
List some antiseptic agents
- Chloramine
- Acetic Acid
- Hibiclens
- Dakins
- Hydrogen peroxide
- Betadine
List some antiseptics for wound healing
- Silver
- Iodine
- Chlorhexidine
- Polyhexamethylbiguande (PMHB)
- Honey
- Acetic Acid
- Potassium Permanganate
Describe silver as an antimicrobial application
- Used as a short term intervention to assist with infection control
- Do not moisten with saline (could deactivate the silver)
- Can’t use with estim (unless cleaned thoroughly)
- Remove from wound before MRI
- use sparingly (for 2 weeks then stop)
Nanocrystaline: effective against MRSA and VRE
Describe Iodine as an antimicrobial application
- Comes in the form of brown powder, paste, or dressing
- It should reduce odor, slough tissue, pain while increasing granulation tissue and decreasing the size of the wound
- Should not be used very often
Describe honey as an antimicrobial application
- Has acidic properties
- No resistance buildup
- Painless
Describe sodium chloride “salt” products as an antimicrobial application
- Can be used in a hypertonic saline solution/dressing form
- Can be used as a hyperosmolar solution
—- May cause excessive fluid removal
—- Do not use on dry wounds
—- Can sting on superficial wounds
Ex: Hypergel and Mesalt gauze
What are 5 ways a clinican can prevent infection?
- Hand washing
- Universal precautions
- Standard precautions
- Sterile and clean techniques
- Transmission-based precautions
What are 3 ways infection can be transmitted?
- Airborne
- Droplet
- Contact
Differentiate between universal precautions and standard precautions
Universal Precautions:
- All blood/fluid is managed as if it is contaminated
Standard Precautions:
- Handwashing
- PPE
- Contact isolation procedures should be followed (if patient has MRSA or VRE wound infection)
- Used for airborne of droplet transmission infections
Differentiate between clean and sterile technique
Clean Technique:
- Not required to change gloves between different ulcers (but treat the worse one last)
- Can use “clean drinking water” rather than saline
- Must use “sterile” dressings
Sterile Technique:
- ONLY STERILE EQUIPMENT/GLOVES MAKE CONTACT W/WOUND
- Used for exposed bone, tendon, organs, severe burns, immunocompromised patient
- Use saline rather than water
How long is saline good for once opened?
24 hours maximum
Explain the infection control procedure
- Hand washing (20 seconds)
- Protect supplies from environment
- Minimize touching the dressings
- Change gloves and wash hands after removing old dressings
- Minimize wound/cross infection
- Red bags (used for infectious waste)
- Sharp containers (for used needles, scalpels, blades)
- Saline (if needed)
What are the primary functions of dressings?
- Protect wound from injury and infection
- Provide a warm/moist environment
- Allows for gas exchange
- Manages drainage
- Provide thermal insulation
- Can control edema
- Promote/enhance wound healing
T or F? Moist environments allow wounds to heal 3-5x faster, facilitate all 3 phases of wound healing, traps endogenous enzymes to facilitate autolytic debridement
True
(And results in more cosmetically appealing scar)
What could happen if a wound is too moist? dry?
Too moist:
- Maceration
- Additional skin damage/ulcer
- Increased chance of infection
Too dry:
- Crust formation
- Lacks enzymes/growth factors
What is a primary layer dressing?
The first layer, also known as “contact layer”, and makes direct contact with wound
Ex: Band-Aid or gauze
What is a secondary layer dressing?
The second layer that is placed over the primary layer
- can provide protection, absorption, occlusion
Describe Gauze/Fiber dressings
Primary or secondary dressing
Uses: Packing, frequent dressing changes (especially when there is high exudate)
Limitations: Highly permeable, frequent changes, higher infection rate, could leave “lint”
- Can be sterile or non-sterile
- Acts as primary or secondary dressing
- Should be applied at an angle when used as a secondary dressing
Describe impregnated gauze dressings
Primary or secondary dressing
Gauze that contains other materials (zinc, petroleum, hydrogel, sodium chloride, iodine, saline)
Uses: Burns, epithelializing and granulating wounds, deep wounds, painful wounds, slough/infected wounds, dry wounds
Limitations: Minimal absorption, requires a secondary dressing
Describe occlusive dressings (moisture retentive)
Primary or secondary dressing
Traps wound fluid (good for autolytic debridement), maintains normal body temp, allows for cell migration, fewer dressing changes
- Should NOT be used with infected wounds
- Should not be used with arterial wounds
Benefits:
- comfortable
- various size/shapes
- can provide thermal insulation
T or F? Immunocompromised patients may require more frequent dressing changes
True
List dressings from Occlusive/Impermeable to Nonocclusive/Permeable
- Latex
- Hydrocolloids
- Hydrogels
- Semipermeable foam
- Semipermeable film
- Impregnated gauze
- Calcium Alginates
- Gauze (fine weave)
- Gauze (loose weave)
Describe transparent/semi-permeable film dressings
Secondary dressing
Benefits: Moisture, autolytic debridement, waterproof, can actually see the wound, permeable to water vapor, impermeable to bacteria and water
Uses: Skin tears, friction abrasions, stage 1 or 2 ulcers, simple wounds
Limitations: Cannot use with highly exudation wounds, can injure peri-wound area
Note:
- Should be discontinued if wound becomes clinically infected
- should not be used on infected wounds, wounds with heavy drainage, patients with fragile skin
Describe foam and semi-permeable foam dressings
Primary or secondary dressing
Benefits: Moisture retentive, autolytic debridement, thermal insulation, permeable to gas but not bacteria, provides moist environment, moderate/high absorbency
Uses: Minor burns, skin grafts, pressure ulcers, venous/diabetic ulcers
Limitations: Not used for dry wounds (would need to add moisture), adhesive can injure peri-wound area (some foams have adhesive, some do not)
Note: can be in place for 5-7 days (or till exudate saturates the edge
Describe hydrogel dressings
Primary dressing
30-90% water based
Benefits: Moisture retentive, autolytic debridement, decrease pressure, EXCELLENT for dry wounds
Uses: Minimal exudating wounds, pressure ulcers stage 2-4, blisters, skin tears, minor burns
Limitations: Not good for large amounts of exudate
Describe Sheet Hydrogel dressings
- Should not use on mod/heavy draining or infected wounds
- Absorbs fluid slowly and minimally
- Might need to be sealed to protect periwound
Describe Hydrocolloid dressings
Primary or secondary dressing
Contains gel forming polymers, and adhesive
Benefits: Moisture retentive, autolytic debridement, thermal insulation, decrease friction, forms to body shape, min/mod absorption
Uses: Pressure ulcers, burns, venous ulcers, dry wounds
Limitations: Potential for hypergranulation, injure periwound, gel may be mistaken for purulent drainage
Contraindications: Bleeding, heavy drainage wounds, dry wounds, arterial ulcers, infected wounds, 3rd degree burns, wounds with exposed structures, patients with poor skin integrity
Note: Should be changed every 5-7 days
Describe Hydro-actives and Super-absorbent polymer dressings
Absorbs more fluid rather than trapping it like foams/hydrocolloids do
Benefits: Highly absorbent, can be used under compression dressings, leaves no residue
Not to be used on clinically infected wounds
Must be changed every 7 days, exudate dependent
Describe alginate dressings
Primary dressing
Benefits: Autolytic debridement, highly absorbent, can be used on infected wounds, provides moist environment,
Uses: Highly exudating wounds, venous ulcers, tunneling wounds, pressure ulcers
Limitations: Not for dry wounds or exposed structures
Contraindications: full thickness burns, dry wounds
Must be changed every 7 days (should be changed daily if infected)
Note: “Hydroactivates” are similar to alginates in regard to absorption but are made of polymer
List some dressings that are good for moisture and exudate
- Alginates
- Hydro-active dressings
- Semipermeable foams
- Hydrocolloids
- Hydrogels
- Semipermeable films
- Gauze
- Non-adherent gauze
Define “synthetic wound dressing”
A type of dressing that covers the wound, absorbs exudate, and mainatins a moist environment
Why is too much exudate a bad thing?
Slows down collagen synthesis and granulation, increases bacterial bio-burden, less chance of periwound damage, provides a moist environment (but not wet)
Describe Biosynthetic and Biological dressings (differentiate between collagen and growth factor forms)
- Tissue from animal or human sources
- Semi-permeable to O2 (allows vapor loss)
Uses: Freshly debrided wounds, chronic wounds
Collagens:
- stimulate fibroblast activity
- used for surgical wounds, burns
- can be used with other topical agents
- Not for necrotic or infected wounds
Growth factors:
- Limited to chronic wounds that did not benefit from traditional intervention
- Requires MD order
T or F? Charcoal helps with wound odor
True
How do primary dressings stay on/in a wound?
With the use of a secondary dressing (unless the primary has adhesive)
- Tape
- Stretch net
- Stretch bandage
List some skin sealants
Wipes or spray (for use on skin that is intact)
List some moisture barriers
- Ointments or creams
- Prevents perineal rashes
- Can apply to macerated skin
Describe the infected wound procedure. List some effective dressings
- Should avoid occlusive dressings
- Re-bandage daily
- Manage exudate properly
Good options for infected wounds:
- Gauze or impregnated gauze
- Alginate (if exudate is heavy)
- Semipermeable foam with antimicrobial
- Silver or iodine
What should you do if a wound is draining vs non-draining?
Draining:
- Absorb moisture
- Protect wound from maceration
Non-draining:
- Provide moisture
- Prevent evaporative fluid loss
When making clinical decisions in regard to wound care, what should you consider?
Is the wound…
- Draining or not draining
- Granular, non-draining
- Granular, draining
- Necrotic, non-draining
- Necrotic, draining
How would you handle a granular, non draining wound?
Goals: Protect periwound area, maintain moist environment
Dressing options:
- Gauze (with topical agent to keep wound moist)
- Impregnated gauze with moisture properties)
- Transparent film (with topical agent underneath)
- Hydrogel (hydrocolloid or foam)
How would you handle a granular, draining wound?
Goals: Observe for infection, absorb exudate, protect peri-wound area
Dressing options:
- Gauze
- Alginate/hydrofibers
- Hydroactives
- Semipermeable foam
- Hydrocolloid (if wound is not infected)
- Impregnated gauze (that has absorption properties such as mesalt… aka sodium chloride)
How would you handle a necrotic, non draining wound?
Goals: Soften and remove eschar, mositen environment, protect periwound
Dressing options:
- Gauze (with topical agent)
- Impregnated gauze
- Transparent film
- Hydrogel (hydrocolloid)
How would you handle a necrotic, draining wound?
Goals: Observe for infection, absorb exudate and remove eschar, protect periwound
Dressing options:
- Gauze
- Alginate/hydrofiber
- Hydroactive
- Semipermeable foam
- Hydrocolloid (if wound is not infected)
- Impregnated gauze (that has absorption properties such as mesalt… aka sodium chloride)
If a wound is infected, how often should it be checked on?
Daily
If a wound is not infected, what would considered an optimal dressing?
- Moisture retentive dressings (with less frequent dressing changes)
T of F? There are gentle and aggressive cleansers
True
T or F? Severely infected wounds may benefit from low % solutions for 1-3 days (used to kill large amount of bacteria)
True
What is the ratio of acetic acid with water for aggressive wound cleansing?
Acetic Acid to Water 1:3
T or F? Arterial wounds should stay dry
True
What is “debridement”? Differentiate between selective and non-selective debridement
The removal of dead/damaged tissue
Selective Debridement:
- The removal of devitalized tissue from a wound using techniques in which the provider HAS CONTROL over which tissue is and is not removed a wound (ex: surgical intervention, enzymatic, autolytic, sharp)
Non-Selective Debridement:
- The removal of all tissue (ex: using dakin’s solution, hydrogen peroxide, wet to dry dressings, whirlpool)
What is the purpose of a debridement?
- Decreases bacterial concentration within the wound bed
- Increase the effectiveness of topical antimicrobials
- Shorten the inflammatory phase
- Decreases wound odor
What are some indications for debridement?
- Necrotic tissue, foreign material
- Removal of calluses (sharp debridement only)
- Large quantity of dead/devitalized tissue
What are some contraindications for debridement?
- Red, granular wounds
- Patients with peripheral artery disease (PAD)
Which wounds require surgical debridement?
- Gangrene tissue / osteomyelitis
- Large pressure ulcers stage III/IV with tunnels or undermining
What are the different methods of debridement?
Surgical/Sharp Debridement: Scissors, scalpels, etc.
Enzymatic Debridement: Collagenase
Autolytic Debridement: When the body heals by itself (use occlussive dressings like films, hydrocolloids, hydrogels, foams overtop)
Mechanical Debridement: Pulse lavage, whirlpool, gauze
Which wounds should be debrided?
- Necrotic tissue
- Avascular
- Callus
- Ones with odor
- Dead fat/fascia
- Foreign debris
Which wounds should NOT be debrided?
- Living tissue
- Fat (yellow/shiny)
- Muscle (dull red)
- Fascia (glistening white)
- Granular tissue
- Viable Tissue
Describe enzymatic debridement
Selective Debridement
- Can be used on infected and uninfected wounds with necrotic tissue
- Should see les necrotic tissue after a few days of use
- Appropriate if the patient cannot tolerate sharp debridement
- Must stay moist
Contraindications: Facial burns, calluses, wounds free of necrotic tissue, wounds with exposed deep tissue
Describe autolytic debridement
Selective Debridement
- Non-invasive, painless
- Can be used on all non-infected wounds with necrotic/slough tissue
- Requires time for debridement to occur
Contraindication: Infected or deep cavity wounds, wounds that requires sharp or surgical debridement
Describe mechanical debridement
Non-Selective or Selective Debridement
Use of force/device to remove devitalized tissue, foreign material, and debris
Non-Selective:
- Wet to dry dressings
- Scrubbing
- Wound cleansers
- Whirlpool
- Pulsatile lavage
Selective:
- Monofilament pads
Describe biological debridement
- Breaks down dead tissue
- Activates infection control and fibroblast migration
(ex: maggots)
Describe sharp debridement
Selective Debidement
The use of scissors or scalpels
Advantage: Rapid removal of dead tissue
Disadvantage: Painful
Indications: Large amount of necrosis, callus, eschar
Contraindications: Gangrene, stable heel ulcers, arterial insufficiency, PAD, ischemic ulcers, stage III/IV with undermining/tunneling
T or F? Autolytic debridement breaks down necrotic tissue slower than enzymatic debridement
True
T or F? Sharp debridement is considered to be “selective”
True
List the debridement techniques from most to least selective
- Sharp
- Monofilament
- Enzymatic
- Autolytic
- Pulse Lavage
What are some indications and contraindications of enzymatic debridement
Indications: infection, to remove eschar, when the patient can’t do sharp debridement, in home or long term care
Contraindications: exposed deep tissue, facial burns, calluses, lack of necrotic tissue, if using silver
What are some indications and contraindications for autolytic debridement?
Indications: moist environment needed, when patient can’t use other forms of debridement
Contraindications: infection, deep cavity, when the patient requires sharp debridement
What are some indications of biological debridement?
Indications: infected wound, to degrade necrosis, when the patient is on antibiotics, to enhance growth factors/angiogenesis
What are some indications and contraindications of sharp debridement?
Indications: infected, dead tissue, necrosis, eschar, chronic wound, calluses
Contraindications: painful, inconsistent training, bleeding risk, gangrene
