Wound Care: Integumentary, Wound Healing, Assessment

Question 1

T or F; the epidermis is avascular

Answer 1

T

Question 2

the dermis is composed of…

Answer 2

elastin and collagen

Question 3

what is underneath the subcutaneous layer

Answer 3

fascia and muscle

Question 4

normal phases of wound healing

Answer 4

1 - inflammation
2 - proliferation
3 - maturation/remodeling

Question 5

signs of inflammation on open wounds

Answer 5

increased drainage, erythema around wound edges

Question 6

what kind of collagen is granulation tissue

Answer 6

3

Question 7

what color is healthy granulation tissue

Answer 7

beefy red

Question 8

during maturation and remodeling, collagen type 1 replaces type 3 in a ratio of

Answer 8

4:1

Question 9

why is it a good idea to do ROM during maturation and remodeling

Answer 9

because collagen aligns along lines of stress

Question 10

T or F: scar tissue contains epidermal appendages

Answer 10

F

Question 11

chronic inflammation and insufficient inflammation are signs of ___ healing

Answer 11

abnormal

Question 12

wound dehiscence (hypogranulation)

Answer 12

scar tissue pulls apart

Question 13

hypergranulation tissue

Answer 13

granulation tissue does not stop once it reaches the wound surface

Question 14

_______ scarring is within the bounds of the original injury while ______ scarring extends outside the bounds of the original injury

Answer 14

hypertrophic
keloid

Question 15

epiboli

Answer 15

premature epithelization
rolled/curled edges

Question 16

wound assessment subjective history components

Answer 16

• demographics
• social history
• occupation
• living environment
• family hx
• fitness, nutrition
• drug/alcohol use
• current conditions
• chief complaint
• function
• meds
• lab measures

Question 17

pressure ulcer risk assessments

Answer 17

braden
norton
gosnell

Question 18

vascular wound risk assessments

Answer 18

doppler ultrasound, ABI

Question 19

neuropathic wound risk assessments

Answer 19

wagner
semmes
monofilament
foot screening tools

Question 20

LE pulses

Answer 20

dorsalis pedis or posterior tib (medial)

Question 21

normal capillary refill

Answer 21

less than 3 seconds

Question 22

ankle brachial index

Answer 22

systolic pressure ankle/systolic pressure brachial

Question 23

is a high number or low number good for ABI?

Answer 23

high, if it is low you have poor healing

Question 24

ABI results dictate…

Answer 24

healing potential
debridement options
LE compression options

Question 25

normal ABI

Answer 25

1.0-1.3

Question 26

ABI > 1.3

Answer 26

non-compressible vessels *commen in diabetics

Question 27

ABI < 0.3

Answer 27

gangrene, emergent vascular consult, may need to amputate

Question 28

if the ABI > 0.8 what level of compression can they have

Answer 28

any level

Question 29

if ABI is 0.6-0.8 what level of compression can they have

Answer 29

20-30 mmHg

Question 30

if ABI is less than 0.6 what level of compression can they have

Answer 30

none

Question 31

if ABI is less than ______ you should not debride

Answer 31

0.5 * they are at 5x greater risk of CV events

Question 32

pitting edema scale

Answer 32

1+ = normal contour, a barely perceptible pit 2+ = fairly normal LE contours with a moderately deep pit 3+ = obvious foot and leg swelling with a deep pit 4+ = severe swelling that distorts the normal contours with a deep pit

Question 33

monofilament for protective sensation

Answer 33

5.07 (10g)

Question 34

monofilament for minimal to no sensation

Answer 34

6.10 (75g)

Question 35

monofilament for normal sensation

Answer 35

4.17 (1g)

Question 36

locations for vibration sense in LE

Answer 36

base of 5th met head navicular medial or lateral malleolus

Question 37

what measurements of a wound should you get

Answer 37

length width longest width depth

Question 38

what method do you use to measure length and width of the wound

Answer 38

clock method (length is 12-6 and width is 3-9)

Question 39

how does the clock face for the foot with the clock method

Answer 39

toes to heel toes = 12, heel =6 *everywhere else is head to toe

Question 40

tract

Answer 40

tunnel that is closed on one end

Question 41

what do you need to make sure is included ina. picture of a wound for documentation

Answer 41

measuring device date patient identifier location

Question 42

eschar

Answer 42

dry necrotic tissue

Question 43

should you remove eschar

Answer 43

it depends if it is stable you can leave it because it acts as a band-aid. but if it is draining or infected it needs to be removed

Question 44

purulent drainage

Answer 44

yellow drainage * a sign of infection

Question 45

serous drainage

Answer 45

clear normal

Question 46

serosaguineous drainage

Answer 46

light pink

Question 47

sanginous drainage

Answer 47

blood

Question 48

T or F: erythema around a wound is normal at the beginning

Answer 48

T: but if is prolonged or spreading it could be a sign of infection

Question 49

induration

Answer 49

hardening of the skin due to inflammation *this is normal at first, but if prolonged it could be a sign of infection

Question 50

maceration

Answer 50

softening of tissue due to excessive moisture

Question 51

hemosiderin staining

Answer 51

the dark purple-brown color of skin due to chronic swelling

Question 52

osteomyelitis

Answer 52

inflammation of bone and bone marrow ** need IV antibiotics

Question 53

do cultures or biopsies provide more details

Answer 53

-biopsies, cultures only tell you about the surface - but biopsies are more invasive and not as quic

Question 54

how to tell the difference between normal inflammation and infection

Answer 54

- are we in the inflammatory phase or is this prolonged? - does it expand out past the wound edges - is the amount/extent disproportionate to size of wound