Wounds

Question 1

Venous insufficiency wounds

Answer 1

Pain with palpation (not very painful)
Pedal pulses present
Irregular edges
Edema
Shallow wound bed
Moist/drainage
hemosiderin staining
proximal to medial malleolus

Most influenced by compression therapy

Question 1

Arterial insufficiency wound

Answer 1

Extreme pain decreased with rest (intermittent claudication)
Decreased/absent pedal pulses
Deceased distal limb temp
Well defined edges
Deep wound bed
Cyanosis, cool skin
Dry
lateral malleoli, dorsum of feet, toes

Question 2

Diabetic ulcer

Answer 2

Painless
Absent pedal pulses
Decreased distal limb temp
Deep wound bed at pressure points
Shiny skin
ulcertion located on weightbearing surfaces of foot

Question 3

Pressure ulcer stages

Answer 3

Suspected deep tissue injury- localized discoloration under intact skin.

Stage 1- intact/red that doesn’t blanch

Stage 2- open wound red/pink wound bed, partial thickness of dermis, blister

Stage 3- subQ fat visible, full thickness, tunneling/undermining, slough possible

Stage 4- tendon, muscle, bone exposed, slough/eschar

Unstagable- slough/eschar covering full thickness

Question 4

Purulent drainage

Answer 4

Thick, white, pus; may be infected

Question 5

Serosanguineous drainage

Answer 5

Contains blood

Question 6

Autolytic debridement

Answer 6

Body uses its own enzymes to lyse necrotic tissue

Question 7

Moisture retentive dressings

Answer 7

Films, hydrocolloids, hydrogels, calcium alginates

Question 8

When is autolytic debridement contraindicated?

Answer 8

Pts who are immunosuppressed

Question 9

Enzymatic debridement

Answer 9

Topical application of enzymes that lyse collagen, fibrin & elastin

Question 10

When is enzymatic debridement indicated?

Answer 10

Stage 3 & 4 wounds with yellow necrotic material

Question 11

Mechanical debridement

Answer 11

Pulsed lavage, whirlpool, dry gauze dressings, irrigation, wet to dry dressings

Question 12

When is enzymatic debridement contraindicated?

Answer 12

Exposed tendons, ligaments, joint capsule, blood vessels,nerves,bone

Question 13

Which dressings CAN be used in infected wounds?

Answer 13

Alginates

Foam - need to be changed daily

Question 14

Safe pressure for pulsed lavage

Answer 14

4-15 psi

Question 15

When to discontinue pulsed lavage

Answer 15

When wound is clean
Wound closure
If no change in necrosis in one week

Question 16

Indications for film dressings

Answer 16

autolytic debridement
Stage I and II pressure ulcers
Skin donor site

NOT with infected wound
Superficial wounds with minimal drainage

Question 17

Indications for foam dressings

Answer 17

Minimal to Moderate drainage
May use with hydrogel for autolytic debridement
Partial or full thickness wounds

Question 18

Indications for hydrogels

Answer 18

Partial and full thickness wounds
Necrosis/slough
Burns
Assist autolytic debridement 
NOT in infected wounds
Most require secondary dressing

Question 19

Indications for hydrocolliods

Answer 19

Partial thickness wounds
Autolytic debridement of necrosis/slough
Mild exudate-Somewhat absorbent/thermal insulation
Occlusive–NOT for infected wounds

Question 20

Indications for alginates

Answer 20

Absorbent - wounds with moderate to large amounts exudate/necrosis
Wounds that require packing
Can be used to control bleeding
Non-occlusive: can use in infected wounds
Require secondary dressing (film/gauze)

Question 21

Indications for gauze

Answer 21

Exudative wounds
Dead space, tunneling, sinus tracts
Exudate/necrosis 
Wet to dry for mechanical debridement 
Can be used on infected wounds
Require secondary dressing

Question 22

Unna boot

Answer 22

Semirigid dressing impregnated with ointments

Used for venous insufficiency ulcers to control edema

Question 23

Which estim protocols can be used for wound care?

Answer 23

High volt pulsatile current***
Microcurrent
Alternating/biphasic current

Question 24

Anode vs cathode for wound care estim

Answer 24

Anode- promote epithelial cell migration, deactivation of inflammatory phase

Cathode- promote granulation, control inflammation & inhibit certain bacteria

Question 26

VAC for wound care

Answer 26

Negative pressure/subatmospheric (125 mmHg below ambient) for any wound
When wound is not closing,lack of arterial perfusion or uncontrolled exudate
Can be used with infection
Open cell foam dressing placed into wound

Question 27

Methods of wound cultures

Answer 27

tissue biopsy, needle aspiration or swab cultures

taken after debridement of thick eschar & necrotic material & wound cleansing

Question 28

Which medications can delay wound healing?

Answer 28

steroids, antihistamines, NSAIDs, oral contraceptives

chemotherapy/radiation

Question 29

When should antiseptics be used?

Answer 29

infected wounds

ex. iodine, acetic acid, hydrogen peroxide

Question 30

Silvadene

Answer 30

primarily for thermal injuries

Question 31

Positioning to prevent pressure ulcers

Answer 31

heels protected/elevated
head of bed not > 30 deg. unless necessary
pressure relief technique ever 2 hour in bed
not weightbearing over greater trochanter
not full weightbearing over existing wound
pillows/wedges to separate bony prominences

Question 32

Can compression be used for arterial wounds?

Answer 32

NO

Question 33

Compression therapy for venous wounds

Answer 33

short-stretch bandages with high working pressure & low resting pressure (calf pump) <40 mmHg at ankle

pneumatic pump can also be used

Question 34

Can compression be used for neuropathic wounds?

Answer 34

dependent on blood flow, check ABI

Question 35

Contraindications to compression therapy

Answer 35

DVT, acute infection, heart failure, hypertension, cardiac/kidney dysfunction, AMS