Wound Care ANTT

Question 1

What is the 5 elements of broaden scale

Answer 1

Sensory perception
Moisture
Activity
Mobility
Nutrition

Question 2

What is the highest and lowest score in the braden score ?

Answer 2

Highest (best) = 20
Lowest (poor) = 6

Question 3

What does TIME stand for in wound care treatment plan ?

Answer 3

Tissue Viability
Inflammation / infection
Moisture level
Edges

Question 4

What is assessed in Tissue viability in TIME?

Answer 4

Describe clinical appearance of wound bed:

• viable or non viable (necrotic, slough)
• skin intact or not intact
• colour of surrounding skin

Question 5

What is assessed in Inflammation of TIME ?

Answer 5

Describe clinical signs of wound infection present

• increasing pain
• increasing heat and temp
• oedema
• erythema of wound and surrounding skin
• inflamed
• yellow slough, biofilm
• malodour
• colour of exudate (thick, milky, green, yellow, brown, red)

Question 6

What is assessed in moisture balance of TIME?

Answer 6

• is moisture balanced or imbalanced ? Too wet or too dry
• maceration of skin indicate too much moisture
• discharge / slough / exudate
• surrounding skin intact / dry and flaky / macerated

Question 7

What is assessed in Edge of TIME ?

Answer 7

• is the wound edge advancing or non advancing ?
• edges are raised and rolled + based of wound deeper than the edge
• colour of edge ( pink indicate new tissue grown & dark edges indicate hypoxia)

Question 8

What is purulent discharge or exudate?

Answer 8

Yellow green thick and sticky discharge

Question 9

What is serous exudate ?

Answer 9

Clear and watery

Question 10

What is haemopurulent exudate ?

Answer 10

Dark blood stained exudate viscous and sticky

Question 11

Describe stage 1 of pressure injury

Answer 11

Intact skin with non-blanchable redness of localised area

Area may be painful and red

Question 12

Describe stage two of pressure injury?

Answer 12

Partial thickness loss of skin dermis presenting shallow open wound with a red pink wound bed (no slough)

Question 13

Describe stage 3 of pressure injury)

Answer 13

Full thickness tissue loss - subcut fat may be visible

Slough may be present

Question 14

Describe stage 4 pressure injury ?

Answer 14

Full thickness tissue loss with exposed bone, tendon or muscle

Slough present

Question 15

Types of wound description

Answer 15

Surgical: suture

Granulating: pinkish red moist tissue present comprise of new collagen formed

Epithelialising: wound surface covered by new epithelium

Slough: devitalised yellow tissue formed

Hyper-granulation: tissue grows above wound margin - prolonged healing

Question 16

Types of absorbent dressings for exudate wounds?

Answer 16

Durafiber: silver impregnated gelling fibre dressing used to pack heavy exudate

Mepilex/Mepitel: minimise removal trauma (ideal for skin tear

Atrauman (Tull Gras)

Exu-dry

Combi-derm

Hydrocolloid Duoderm

Alginate Kaltostat: absorb heavy exudate

Question 17

Dressings for hydration

Answer 17

• hydrogel sheets for dry necrotic tissue

Question 18

Antimicrobial dressings

Answer 18

Inadine: non adherent Iodine dressings

Bactigrass: Antiseptic Tull grass

Anticoat: Silver dressing

Question 19

What is an illeostomy?

Answer 19

Opening in the Terminal ilium small intestine

Stool: Brown watery custard consistency

Usually right side

Question 20

What is a colostomy?

Answer 20

Opening in colon large intestine

Usually eft side

Output: brown and soft to more normal like consistency

Question 21

Observation when checking stoma site?

Answer 21

1. Colour (bride red is good blood supply)
2. Protrusion (ideal site must be raised 2-3cm above abdo wall) retracted?
3. Peristomal skin (surrounding skin is eroded or rash ?)
4. Output

Question 22

How to prevent pressure injury ?

Answer 22

Routine Pressure area care

Sacrum foam or silicon and heal foam

Routine skin check and care.

Nutrition

Supporting bed device and mattress

Pillows in between legs

Moisturising skin

Question 23

Difference between venous and arterial leg ulcers?