Wound Care 3

Question 1

3 types of wound drainage

Answer 1

serous
sanguineous
purulent

Question 2

serous wound drainage

Answer 2

pale yellow or transparent fluid from body cavities

Question 3

sanguineous wound drainage

Answer 3

color of blood or containing blood

Question 4

purulent

Answer 4

possible infection

production of pus

Question 5

When should odor be assessed?

Answer 5

after debridgement and rinsing

should be described as present of not present

Question 6

What is Turgor?

Answer 6

sign of dehydration

you pull up skin on back of hand for few seconds and see how quickly it returns to normal

Question 7

Color-hyperpigmentation

Answer 7

long standing venous insufficiency

Question 8

color-blue

Answer 8

prolonged ischemia

Question 9

Color-lighter/paler

Answer 9

means decreased blood supply or newly formed scar tissue

Question 10

What does it mean if wound is nonblanchable?

Answer 10

ischemic damage due to unrelieved pressure

Question 11

What is induration?

Answer 11

firm edema

Question 12

Measuring Temperature

Answer 12

measure with dorsum of hand after pt has rested in supine for 5 min.
compare to proximal body segments
Increased temp=inflammation or infection

Question 13

Purposes of debridement

Answer 13

decrease bacterial concentraion/infection risk
increase effectiveness of topical antimicrobials
improve bactericidal activity of leukocytes
shorten the inflammatory phase of wound healing
decrease energy required by body for wound healing

Question 14

What does black wound bed indicate?

Answer 14

covered in eschar
indicates full thickness wound probably
should be debrided

Question 15

Yellow wound means what?

Answer 15

draining wound covered with slough
may result from partially removed eschar of black wound or may represent more superficial wound.
moisture=bacteria growth and maceration

Question 16

Red wound means what?

Answer 16

granular wound (red and ready to heal)
should not be debrided
should be protected in a warm, moist environment

Question 17

Should calluses be debrided?

Answer 17

yes possibly

if large fluid filled blisters, over joint, or burn blisters, they may need to be debrided.

Question 18

Contraindications for PT debridement

Answer 18

red, granular wounds
surgical debridement (deep tissues, undermining stage 4, electrical burns, and gangrenous tissue

Question 19

Two types of debridement

Answer 19

selective

non selective

Question 20

4 methods of debridement

Answer 20

sharp (selective)
autolytic (selective)
enzymatic (selective)
mechanical (non selective)

Question 21

Sharp debridment

Answer 21

selective
fastest, most aggressive method outside of surgery
may be done by PTs but not PTAs

Question 22

When is sharp debridement indicated?

Answer 22

large amount of necrosis
advancing cellulitis
advancing sepsis
wounds w/necrotic tissue

Question 23

When is sharp debridement contraindicated?

Answer 23

area can’t be seen because of tunneling/undermining
material to be debrided can’t be identified
on uninfected ischemic ulcers

Question 24

Definition of Autolytic debridement (selective)

Answer 24

uses body’s own enzymes, including collagenase to digest necrotic tissue by applying moisture retentive dressing and leaving it in place several days

Question 25

Facts about autolytic debridement

Answer 25

most conservative, least invasive, least painful takes min. time reduces cost over long term easy to teach pts/clinicians doesn't allow frequent visual of wound bed and you have to wait a few days for it to work

Question 26

Indications for autolytic debridement

Answer 26

wound that contains necrotic tissue | pt who can't tolerate other forms of tx

Question 27

Contraindications for autolytic debridement

Answer 27

infected wounds | wounds needing sharp or surgical debridment

Question 28

What is enzymatic debridment? (selective)

Answer 28

use of topical exogenous enzyme to remove devitalized tissue | can be done by PTA

Question 29

About enzymatic debridement

Answer 29

``` need physicians prescription don't need as much skill less painful than others (beside autolytic) can be expensive/time consuming less effective ```

Question 30

Types of enzymatic debridement

Answer 30

proteolytics-family of proteins that degrade necrotic debris fibrinolytics=breaks down blood clot collagenases-promote cellular response to injury

Question 31

Indications for enzymatic debridement

Answer 31

infected and uninfected wounds w/necrotic tissue pts who can't tolerate sharp debridement adjunct to sharp or mechanical debridement between sessions home care or LTC settings

Question 32

Contraindications

Answer 32

``` wounds w/exposed deep tissues when sharp or surgical debridement is required facial burns wounds with no necrotic tissue wounds being autolytically debrided ```

Question 33

What is mechanical debridement?

Answer 33

nonselective | use of force to remove devitalized tissue, foreign material, and debris.

Question 34

What is Wet-to-dry mechanical debridement

Answer 34

applying single layer of fluffed saline moistened gauze to necrotic wound, covering w/more gauze, then allowing to dry 8-24 hours. When it's dry, it's torn away at right angle.

Question 35

About wet to dry mechanical debridement

Answer 35

removes viable AND nonviable tissue risk of perwound maceration and fungal infection less effective than enzymatic and autolytic only indicated in wounds with 100% devitalized wound beds.

Question 36

What is mechanical "scrubbing" debridement?

Answer 36

use of sponge, brush, or gauze along with a fluid to break the adherence of devitalized tissue and debris from wound bed.

Question 37

About "scrubbing" debridement

Answer 37

can remove or traumatize viable tissues as well contraindicated for granulating wounds high porosity sponge and LITTLE force is recommended. begin at wound center and work out to avoid contaminating cleansed areas.

Question 38

What is wound cleansing?

Answer 38

delivery of wound cleanser to wound surface using mechanical force to remove lightly adhered necrotic tissue, debris, and bacteria.

Question 39

Facts about wound "cleanser"

Answer 39

cleansers often contain antiseptic and have antimicrobial properties. They aren't FDA approved they have been found to contain cytotoxic agents that delay wound healing.

Question 40

7 main purposes of whirlpool

Answer 40

debride loosely adherent devitalized tissues soften necrotic tissue and eschar hydrate the wound bed/ promote healing promote circulation reduce pt pain complaints during wound care ease ROM can soak off adherent dressings

Question 41

Indications for whirlpool

Answer 41

infected wound nondraining wound wound with thick eschar wound with loosely adherent necrotic tissue

Question 42

Contraindications for whirlpool

Answer 42

clean, granulating wounds tunneling wounds or wounds w/undermining wounds in areas of skin folds

Question 43

What is pulsed lavage w/concurrent suction?

Answer 43

delivery of wound irrigant under pressure by an electrically powered device and removal of irrigant with negative pressure.

Question 44

Advantages of pulsed lavage

Answer 44

``` removal of irrigant decreased tx cleanup portable shorter tx time lower cost less risk of cross contamination less physiological stress less painful than whirlpool better ergonomics for clinician ```

Question 45

Disadvantages of pulsed lavage

Answer 45

one time use tubing and wound tips=increased cost | not appropriate for extensive wounds

Question 46

Indications for pulsed lavage

Answer 46

cleansing or debriding wounds due to arterial insufficiency, venous insufficiency, diabetes, pressure, small burns, surgery, or trauma

Question 47

contraindications for pulsed lavage

Answer 47

``` near exposed arteries, nerves, tendons, bones in body cavities facial wounds recent grafts or surgical procedures wounds that are actively bleeding ```

Question 48

What is Negative pressure wound therapy?

Answer 48

subatmospheric pressure to wound using electrical pump to intermittently or continuously convey pressure through connecting tubing to a specialized wound dressing to promote healing.

Question 49

Advantages of negative pressure wound therapy

Answer 49

``` moist wound environment establish fluid balance removal of slough reduction in edema and 3rd space fluids potential decrease in wound bacteria increase blood to wound increase growth factors by approximation promotion of white cells and fibroblasts in wound ```

Question 50

Disadvantages of negative pressure wound therapy

Answer 50

one time use for tubes and supplies | not ideal for all pts

Question 51

Indications for negative pressure wound therapy

Answer 51

``` pressure ulcers stage 3 &4 ortho trauma wounds diabetic ulcers post op flaps open abdominal and surgical dehisced wounds partial thickness wounds ```

Question 52

Contraindications for negative pressure wound therapy

Answer 52

``` malignancy untreated osteomyelitis exposed blood vessels necrotic tissue with eschar or slough nonenteric or unexplored fistula bleeding disorder untreated malnutrition ```