Day 2

Question 1

Pressure wound -At risk pts

Answer 1

Elderly 
Immobile
Very sick, hypotension
SCI
CVA

Question 2

Main causative factor of pressure sores

Answer 2

Immobility

Question 3

Pathology of pressure due to

Answer 3

Intensity of pressure
Duration of pressure
Tissue tolerance

Question 4

Capillary closing pressure

Answer 4

12-32 mmHG

Question 5

Duration of pressure in conductivity w/ intensity

Answer 5

Long/low = damage
Short/high = damage

Question 6

Tissue tolerance

Answer 6

Skin and tissue ability to transmit load

-reduced by shear, friction , moisture, malnutrition, low BP, impaired perfusion, stress, smoking, fever, anemia

Question 7

Deep tissue pressure injury

Answer 7

Persistent non-blanchable deep red, maroon or purple discoloration

Question 8

Unstageable pressure injury

Answer 8

Obscured full thickness skin and tissue loss

Look at slides

Question 9

Stage 1 pressure injury

Answer 9

Non blanchable erythema of intact skin

Question 10

Stage 2 pressure injury

Answer 10

Partial thickness skin loss w/ exposed dermis

Question 11

Stage 3 pressure injury

Answer 11

Full thickness skin loss

Question 12

Stage 4 pressure injury

Answer 12

Full thickness and tissue loss

Question 13

Wounds that are classified differently than pressure injury

Answer 13

Moisture associated w/ skin damage
Medical device related pressure injury
Mucosal membrane pressure injury

Question 14

Tx cause of pressure injury

Answer 14

Help nursing ed and reposition every 2 hours
Keep pt off existing pressure injuries
Increase mobility and independence
Monitor skin closely during tax
Place decides on properly
Help w/ preventative measures and support surface adherence

Question 15

Aging skin - physiological changes

Answer 15

Decrease in keratinocyte proliferation 
Decrease in keratinocyte renewal rate 
Drop in melanocyte levels 
Decline in Langherhans cell count
Reduced vascularity 
Subcutaneous tissue flattens 
Collagen, elastin, and glycosaminoglycans are
altered, reducing skin strength and flexibility 
Reduced sebaceous gland output

Question 16

Aging skin results of cellular changes

Answer 16

Dry skin (xerosis)
More susceptible to blisters
More susceptible to skin and deep tissue injury
Increased rate of skin cancers
Slow healing of wounds, whether simple or complex
Increased risk for wound infections Pro-inflammatory environment

Question 17

Urinary and fecal incontinence may lead to

Answer 17

Dermatitis
Fungal infection
Colliculitis

Question 18

Wound bed prep

Answer 18

DIME
Debridement
Infection/inflammation
Moisture balance
Epithelialization advancement (edge)

Question 19

Debridement removes

Answer 19

Non vascular tissue
Bacteria
Cells that impede healing process

Stimulates healthy tissue formation
Faster wound closure

Question 20

Benefits of debridement

Answer 20

Reduce risk of infection
Reduce abscess formation risk
Reduce odor
Reduce inflammation

Question 21

Sharp debridement done by

Answer 21

Performed by PT,PTA,MD,PA,RN

RNs must be signed off by MD initially

Question 22

Types of debridement

Answer 22

Sharp
Sx
Mechanical
Autolysis
Enzymatic
Biosx
Low frequency US

Question 23

Normal BUN

Answer 23

8-25 mg/dL

Elevated = delayed wound healing

Question 24

Glucose normal

Answer 24

70-120 mg/dL

Question 25

Hemoglobin norm

Answer 25

13-18 men 12-16 women Decreased = less O2 carried to tissues, slower healing

Question 26

INR norm

Answer 26

0.9-1.2 | >2 =relative contraindication to debridement

Question 27

Protime norm

Answer 27

11-13.5 seconds | Elevated = impaired clotting if bleeding occurs

Question 28

Platelets norm

Answer 28

130-400 | Decreased impaired clotting if bleeding occurs

Question 29

Lab values for debridement

Answer 29

Hemoglobin <12 IRN >2 Platelets <130

Question 30

Sharp debridement precuations

Answer 30

``` Low RBC, Hct, Hgb Marginal platelet levels Poor med status/prognosis On Coumadin w/ marginal INR Near deep structures Hands, genital areas ```

Question 31

Sharp debridement contras

Answer 31

``` Stable eschar Poor med status/poor prognosis Patient on IV heparin Low platelet count IRN above 2.0 Gangrene of toes or fingers ```

Question 32

Mechanical debridement

Answer 32

Non-discriminatory physical force to remove necrotic tissue Gauze, whirlpool, pulsatilla lovage May slow wound healing process

Question 33

Autolytic debridement

Answer 33

Promotes phagocytic activity and formation of granulation tissue Achieved by a moist wound enviro, use of impermeable, semipermeable, or most dressings

Question 34

Enzymatic debridement

Answer 34

Active enzyme therapy that continuously removes necrotic tissue form wound Collagenase selectively target collagen strands that hold cellular debris to wound bed Collagenase saintly May be used in conjunction w/ sharp debridement

Question 35

Biosx debridement

Answer 35

``` Rapid but selective Reduces bacterial burden Possible control of MRSA Stimulates granulation tissue formation No reported toxicity ```