Wound Care Examination

Question 1

What are the normal lab values of Hgb? Hcrt? Blood glucose? WBC? albumin?

Answer 1

Hgb = Women: 12-16 g/dL, Men: 14-18 g/dL

Hcrt = Women: 38-46%, Men: 42-54%

Glucose = 70-110 mg/dL

WBC = 4500-11k

Albumin = 3.5-5.5 g/dL

Question 2

Why is it important to ask if patients have had wounds before?

Answer 2

previous wound in the same place makes it more difficult to treat
- pt expectations and perceptions about wound healing are very important as well

Question 3

Why would you need to screen urogenital system in wound healing?

Answer 3

incontinence is correlated with an increased risk of pressure ulcers

Question 4

wound measurement technique that measures the longest part of the wound x longest perpendicular line

Answer 4

direct method

Question 5

wound measurement technique that measures the longest 12-6 measurement x longest 9-3 measurement

Answer 5

clock method

Question 6

wound measurement technique that uses a clear sticker placed on the wound that is traced, then paper is stuck into chart; count squares for area

Answer 6

square-counting method/ tracing

Question 7

when would it be indicated to use volumetric measurements for wound size?

Answer 7

tunnelling wounds

Question 8

What characteristics are necessary to document?

Answer 8

1. Wound bed
2. Wound edges
3. Presence of tunneling/ undermining
4. Wound drainage
5. wound odor

Question 9

What characteristics of the wound bed should be noted?

Answer 9

1. Granulation tissue
2. Necrotic tissue - slough or eschar; adherent vs nonadherent to wound bed
3. Other structures- fascia, bone, muscles, staples, etc.

Question 10

What characteristics of the wound edges should be noted?

Answer 10

1. distinctness - irregular vs well defined
2. thickness- hyperkeratosis
3. color
4. attachement to base of wound (attached heal more quickly)

Question 11

What characteristics of the wound drainage should be noted?

Answer 11

1. Type: serous (n), sanguineous (n), sersanguinous (n), purulent (inf), or seropurulent (inf)
2. Color: clear (n), pale yellow(n), red, dark brown, blue-green (inf)
3. consistency: thin and watery (n), thick (inf)
4. amount: none (dessicated), minimal (n), moderate (n), copious (inf)

Question 12

What are the periwound characteristics that should be documented?

Answer 12

1. structure and quality - age related skin, hydration, turgor, calluses, scar formation
2. color - redness
3. edema - pitting edema scale
4. temp
5. presence of hair (v insuf often see loss of hair)

Question 13

What are pulse grades given for circulation?

Answer 13

0 = absent
1+ = diminished pulse
2+ = normal pulse
3+ = bounding or accentuated

Question 14

What is the normal capillary refill time?

Answer 14

<3s

Question 15

What are the monofilament measurements for sensoring testing?

Answer 15

4. 17 (1 gm) = decreased sensation
5. 07 (10 gm) = loss of protective sensation RED FLAG; increased risk of ulcers
6. 10 (75 gm) = absent sensation

Question 16

Standard in wound care, and in Arterial Vascular assessments - Ratio; LE pressure/arm pressure

Answer 16

Ankle Brachial Index (ABI)

Question 17

taking BP at various area of the body; looking for a drop (will be a small one naturally as move distal, but is it significant amt); Don’t want a drop of >20! if taken, usually take ABI first, and this is a progression of it: taken at high thigh, low thigh, below knee, and above ankle

Answer 17

Segmental Pressures

Question 18

Circulation test: elevate extremity testing ~60*; looking at plantar surface of, foot hold for 1 minute; is there color change?

Answer 18

Rubor of dependency

• (+) Test = whiteness/palor noted after 60 seconds of elevation, then immediate redness when sit pt up and bring foot back to dependent position
• Indicates Areterial Insufficiency

Question 19

Circulation test: • pt supine, elevate extremity testing ~60*; looking at dorsum of foot hold for 1 minute return pt to dependent position how long does it take for color to return

Answer 19

Venous filling time

• Normal Venous Filling Time = 5 – 20 seconds
• <5 seconds = Venous Insufficiency
• > 20 seconds = Arterial Insufficiency

Question 20

What are some wound healing assessment tools?

Answer 20

• Bates-Jensen Wound Assessment Tool (BWAT) previously PSST
• Pressure Ulcer Scale of Healing (PUSH)
• Sussman Wound Healing Tool (SWHT)

Question 21

What are local clues to infection?

Answer 21

1. Redness disproportionate or streaks*** (out of wound margins)
2. Increased temp over wider area (not just at wound)
3. Swelling disproportionate
4. New onset or increase in pain
5. Thick copious drainage
6. Drainage white, dark yellow, green, or blue - Changes in drainage color/odor/thickness
7. Distinctive odor

Question 22

What are systemic clues to infection?

Answer 22

1. Fever
2. Malaise
3. Leukocytosis
4. Mental status change
5. Tachycardia
6. Hypotension

Question 23

What is the difference between inflammation and infections?

Answer 23

• inflammatory responses are local to the wound and don’t extend much beyond the injury where infection does and has systemic effects
• inflammation follows the normal phases of healing if treated appropriately, infection plateaus and there are changes in the granulation tissue not consistent with proper healing

Question 24

How do you diagnose wound infection?

Answer 24

1. Tissue Biopsy (gold standard)
2. Fluid Aspiration
3. Swab Culture (used by PTs)

Question 25

What are indications of a swab culture?

Answer 25

1. Pt. exhibits signs and symptoms of infection

2. Pt. presents with a nonhealing wound despite appropriate wound management

Question 26

What is the procedure of a swab culture?

Answer 26

1. Obtain physician’s order
2. Debride necrotic tissue and rinse with saline - Clean to get to actual wound bed, so you’re not just pulling from the surface/what isn’t penetrating wound
3. Remove and discard soiled gloves
4. Obtain a culturette and label it with date, pt’s name, and site cultured
5. Put on clean gloves
6. Follow a zig zag pattern (see pic) to sample all areas of wound bed
7. Rotate the applicator while traveling over the wound bed
8. Replace the applicator into the culturette
9. Squeeze the ampoule of fluid at the bottom to bathe the applicator
10. Place culturette in a labeled biohazard bag and send to lab
11. Perform separate cultures on each wound

Question 27

What is diagnosis based on in terms of etiology?

Answer 27

1. Depth
2. Staging System (pressure ulcers)
3. Wagner (diabetic ulcers)
4. Degree (burns)

Question 28

What is a good prognostic indicator?

Answer 28

20-40% decrease in wound surface area within 2-4 weeks

- indicates wound is responding and full closure will take place