Wound Care

Question 1

Name the six describing factors of a wound

Answer 1

1. Location
2. Duration
3. Size (length, width, depth)
4. Exudate (odor, quality & quantity)
5. Appearance of wound bed and border - (eschar, gran tissue, infection, necrosis, slough, fibrous tissue, color)

Question 2

Name the 4 stages of pressure ulcer staging.

Answer 2

1. Skin is unbroken but inflamed.
2. Skin is broken to dermis or epidermis
3. Ulcer extends to subcutaneous fat layer
4. Ulcer extends to muscle or bone (undermining likely)

Question 3

5 stages (including 0) of Wagner’s Diabetic Foot Wound Classification

Answer 3

0. Intact skin but pressure/erythema or callus noted
1. Superficial ulcer without penetration to deeper layers
2. Deep ulcer which reaches to tendon, bone, or joint capsule
3. Deeper ulcer with abscess, osteomyelitis, or tendonitis.
4. Gangrene of some portion of the toes, and/or forefoot which may be wet or dry
5. Gangrene involves the whole foot

Question 4

Define superficial, partial and full thickness wounds

Answer 4

Superficial: Involving but not through the epidermis
Partial: epidermis and partial dermis
Full: through dermis and into subcut tissue

Question 5

Five clues of wound infection

Answer 5

1. Increased pain
2. Increased or discolored drainage
3. foul odor
4. Periwound erythema
5. failure to heal in timely fashion

Question 6

6 types of etiology for wound

Answer 6

1. Pressure ulcer
2. Arterial insufficiency
3. Neuropathic (diabetic) ulcer
4. Venous stasis ulcer
5. Wound dehiscence
6. Burns

Question 7

Ischemic Ulcers:

1. Location:
2. Pain
3. Appearance:
4. Pulses:
5. Skin:
6. Bleeding:
7. Edema:
8. Risk Factors:
9. Key treatment:
10. If delayed healing:

Answer 7

1. Toes, heels, lateral mall
2. Present, relieved w/ dependency
3. Pale, irregular, dry, poor
4. pulses: poor/absent
5. Skin: thin, shiny, dry, hairless, thick nails
6. Bleeding: poor
7. Edema : none; atrophy
8. Smoking, CM, age, CAD
9. Revascularization
10. infection, restenosis

Question 8

Venous:

1. Location:
2. Pain
3. Appearance:
4. Pulses:
5. Skin:
6. Bleeding:
7. Edema:
8. Risk Factors:
9. Key treatment:
10. If delayed healing:

Answer 8

1. Lower leg (gaiter), above med mall.
2. Relieved with elevation
3. Beefy red granulation and/or slough. Sloping edges.
4. Present
5. venous
6. present
7. varicose veins, prior DVT
8. compression
9. occult ischemia, inadequate compression.

Question 9

Neuropathic/Diabetic Ulcer

1. Location:
2. Pain
3. Appearance:
4. Pulses:
5. Skin:
6. Bleeding:
7. Edema:
8. Risk Factors:
9. Key treatment:
10. If delayed healing:

Answer 9

1. Plantar
2. Absent
3. Deep tract, punched out
4. Normal
5. Normal/callused
6. Brisk
7. none
8. DM, Immobility
9. Off loading
10. Occult ischemia, osteomyelitis

Question 10

6 etiologies of pressure ulcers

Answer 10

1. Long periods of low pressure
2. Short periods of high pressure
3. Friction
4. Moisture
5. Shear
6. Positioning.

Question 11

Positioning affects location of ulcers:

1. Supine (2)
2. Lat recumbant (2)
3. Upright in chair (1)

Answer 11

1. sacrum/coccyx, heel
2. Lat mall, greater troch
3. Ischial tuberosity

Question 12

3 ways to maximize health in wound patients

Answer 12

1. Stop smoking
2. tight control of DM and HLD
3. Adequate nutrition and exercise.

Question 13

Three ways to improve wound bed

Answer 13

1. Reduce edema
2. Reduce bioburden: debridement, topical abx, clean frequently
3. keep bed moist.

Question 14

Debridement frequency:

Do not debride if:

Answer 14

q1-4 weeks

a suspected arterial wound exists until you check ABI’s and doppler

Question 15

Normal ABI;
Abnormal:
<______: at risk for:

Answer 15

> 0.95
0.6-0.9 abnormal
biphasic >monophasic > flat. Refer to vascular surgery for revascularization if abnormal first

Question 16

four types of debridement

Answer 16

1. Sharp (scalpel)
2. Mechanical (wet-to-dry dressing. pulse lavage)
3. Enzymatic (santyl)
4. Autolytic (duoderm)

Question 17

Exception to moist wound bed rule:

Answer 17

Do not introduce moisture into a wound that has dry gangrene until revascularization has been performed.

Question 18

Four benefits of moist content

Answer 18

1. traps endogenous enzymes
2. prevents scab/eschar formation
3. facilitates autolytic debridement
4. moist wounds heal 3-5x faster

Question 19

Three functions of wound dressing

Answer 19

1. Controls moisture
2. fills dead space
3. Thermoregulation

Question 20

7 types of occlusive dressings from permeable to impermeable:

Answer 20

1. Gauze (permeable)
2. Alginate
3. Impregnated Gauze
4. Semipermeable film
5. Semipermeable foam
6. Hydrogel
7. Hydrocolloid (impermeable)

Question 21

4 benefits of gauze dressing

Answer 21

1. cheap
2. ok to use on infected wounds
3. can pack tunnels/undermining
4. mechanical debridement if used wet-to-dry

Question 22

4 limitations to gauze

Answer 22

1. Higher infection rate
2. requires frequent dressing changes
3. may adhere to wound bed (painful)
4. nonselective debridement

Question 23

How do calcium alginates work?

Answer 23

react with wound exudate to form a hydrphilic gel, providing moist environment. Highly permeable and non-occlusive. Comes in sheets and ropes.

Question 24

Limitations to calcium aginate dressing:

Answer 24

do not use on exposed tendon or bone.

Question 25

Examples of impregnated gauze:

Answer 25

1. xeroform | 2. adaptic

Question 26

3 benefits of impregnated gauze

Answer 26

1. good for granulating tissue that does not require debridement or moisture modification. 2. not painful when removed or changed. 3. non-adherent

Question 27

Limitations of impregnated gauze

Answer 27

no absorptive properties

Question 28

4 benefits of semipermeable films:

Answer 28

1. Moisture retentive 2. Allow visualization of the wound 3. waterproof 4. reduce friction

Question 29

3 Limitations of semipermeable films:

Answer 29

1. No absorptive properties 2. Cannot be used on infected wound 3. Can traumatize wound w/ removal (highly adherent)

Question 30

2 examples of semipermeable films

Answer 30

tegaderm, opsite

Question 31

5 benefits of semipermeable FOAMS

Answer 31

1. Moisture retentive 2. Thermal insulation 3. Cushioning 4. adherent and non-adherent 5. absorb moderate exudate

Question 32

Limitations of semipermeable FOAMS

Answer 32

caution on infected wounds

Question 33

two examples of semipermeable FOAMS

Answer 33

curafoam, mepilex

Question 34

Uniqueness of semipermeable foams

Answer 34

hydrophilic inside and hydrophobic outside (so absorbs moisture but prevents external contamination)

Question 35

3 benefits of hydrgel

Answer 35

reduces pressure, usually non-adherent, donates moisture to the wound.

Question 36

Unique thing about hydrogel (2)

Answer 36

comes in sheets or gels, water or glycerin based

Question 37

2 examples of hydrgel

Answer 37

aquasorb, curagel

Question 38

2 limitations of hydrogel

Answer 38

1. cannot use on highly exudative wounds. | 2. do not use on infected wounds

Question 39

3 uses of hydrocolloid dressing

Answer 39

1. highly absorptive 2. promotes autolytic debridement 3. cushion

Question 40

2 limitations

Answer 40

1. May cause hypergranulation (due to excessive moisture buildup) 2. May roll in areas of friction 3. cannot use on infected wounds

Question 41

Uniqueness of hydrocolloid dressing

Answer 41

impermeable to external fluid/bacteria

Question 42

Example of hydrocolloid

Answer 42

duoderm

Question 43

Name 5 examples of biosynthetic dressings and skin substitutes for chronic wounds:

Answer 43

Oasis, integra, dermagraft, apligraf, epifix (contains various amounts of keratinocytes, fibroblasts, collagen, growth factors, etc) (use to stimulate granulation in chronic wound that has minimal slough or fibrous tissue)

Question 44

Name 2 growth factors: | Used for:

Answer 44

1. regranex, promogran | 2. stimulates granulation in chronic wound that has minimal slough or fibrous tissue.

Question 45

What is hydrofiber

Answer 45

such as aquacel ag | Do not use on dry wound bed, pack into wound and it absorbs moisture