Wounds

Question 1

how to determine risk of foot pressure ulcer

Answer 1

pressure threshold using nylon filaments

Question 2

Pressure ulcer staging

Answer 2

Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching, but instead present as local coloration differing from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

Stage II: Partial-thickness tissue loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed. May present as an intact or ruptured serum-filled blister or presents as a shiny or dry shallow ulcer without slough or bruising.

Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining and tunneling. Bone and tendon are not visible or directly palpable.

Stage IV: Full-thickness tissue loss with exposed bone, tendon or muscle that is visible or directly palpable. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling may be present. The depth of a stage IV pressure ulcer varies by anatomical location.

Unstageable: Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

Question 3

Dressings: hydrocolloids

Answer 3

gel-forming with strong film or foam adhesive backing

indications: full and partial thickness wounds, granular or necrotic wounds

provides moist healing environment, enables autolytic debidement, moderate absorption, do use on infected wounds

Question 4

Dressings: hydrogels

Answer 4

gel-forming

indications: superficial or partial-thickness wounds with minimal drainage.

moisture retentive
provides moist healing environment, enables autolytic debridement, minimally adheres to wound, not for wounds with significant drainage

Question 5

foam dressings

Answer 5

hydrophilic at wound and hydrophobic at outer surface

indications: provide protection over partial and full thickness wounds with varying level of exudate

provides moist healing environment, encourages AD, moderate absorption

Question 6

Dressings: transparent film

Answer 6

indications: superficial wounds or partial thickness wounds with minimal drainage

moist healing environment, enables autolytic debridement, resistant to shearing forces. not for infected wounds. excessive exudate can lead to maceration

Question 7

Dressings: gauze

Answer 7

infected or non-indfected wounds, readily available

tendency to adhere to wound bed

Question 8

Dressings: alginates

Answer 8

extracted from seaweed

highly permeable and non-occlusive. require secondary dressing.

indications: partial or full thickness, pressure or VI ulcers, used on infected wounds

high absorptive capacity, enables autolytic debridement, not for wounds with exposed tendon, joint capsule, or bone

Question 9

Burn agents

Answer 9

Topical Agents Used in Burn Care

Silver Sulfadiazine

Advantages: Can be used with or without dressings; is painless; can be applied to wound directly; broad-spectrum; effective against yeast

Disadvantages: Does not penetrate into eschar

Silver Nitrate

Advantages: Broad-spectrum; non-allergenic; dressing application is painless

Disadvantages: Poor penetration; discolors, making assessment difficult; can cause severe electrolyte imbalances; removal of dressings is painful

Povidone-iodine

Advantages: Broad-spectrum; antifungal; easily removed with water

Disadvantages: Not effective against pseudomonas; may impair thyroid function; painful application

Mafenide Acetate

Advantages: Broad-spectrum; penetrates burn eschar; may be used with or without occlusive dressings

Disadvantages: May cause metabolic acidosis; may compromise respiratory function; may inhibit epithelialization; painful application

Gentamicin

Advantages: Broad-spectrum; may be covered or left open to air

Disadvantages: Has caused resistant strains; ototoxic, nephrotoxic

Nitrofurazone

Advantages: Bacteriocidal; broad-spectrum

Disadvantages: May lead to overgrowth of fungus and pseudomonas; painful application