EXS 295 Wound Care

Question 0

Inflammation

Answer 0

Characterized by hemostasis (stoppage of bleeding) and cleaning wound bed

Question 1

3 phases of normal wound healing

Answer 1

• inflammation (up to day 10)
• proliferation (day 3-20 )
• maturation and remodeling (day 9-2 yrs)

Question 2

Proliferation

Answer 2

Partial thickness dine by epithelialization (building of new skin cells), full thickness dine by granulation and contraction

Question 3

Maturation and remodeling

Answer 3

Tensile strength increases, scar tissue is 80% original strength, which explains reulcerations

Question 4

Chronic wounds

Answer 4

Wounds that have stalled in a normal wound healing phase

Question 5

Moist wound healing

Answer 5

-modern wound management standard of care

Keep wound covered until completely healed

Question 6

Why moist wound healing

Answer 6

• good fluids carrying healing cells stay in wound bed
• soften scab Escher (scabs hold bacteria beneath then and create scars)
• maintenance of warm environment
• provides protection
• increased patient comfort

Question 7

Wound characteristics

Answer 7

• location
• staging (stage of healing)
• size
• drainage
• inflammation
• undermining/tunneling
• odor
• type of wound tissue
• depth
  - superficial (epidermis)
  - Partial (epidermis and dermis)
  - full (loss into deeper structure)

Question 8

Venous ulcers

Answer 8

• most common
• inadequate drainage of venous blood from a body part. Causes edema, changes in skin, and ulcerations
• predictors: aging, lack of exercise, pregnancy, long hours of siting, standing, walking, heredity
• heavy drainage, absorptive dressing

Question 9

Arterial ulcers

Answer 9

• insufficient blood flow (not enough O2) most often sure to peripheral vascular disease (PVD)
• predictors or PVD: smoking, cardiac disease diabetes, hypertension, renal disease, elevated cholesterol and triglycerides
• usually on lower extremities, painful wounds, decreased pulses, abnormal toenails, pale, dry, cool skin, lack of hair growth
• refer to physical to restore blood flow

Question 10

Diabetic (neuropathic) ulcer

Answer 10

• insensate foot (problems with sensation in foot) either sustains trauma or gets repeated insults that the patient does not notice
• usually located on weight bearing surfaces
• normally get blisters they can’t feel
• difficult to treat if patient is non compliant
• off load wounds and glycemic control

Question 11

Pressure ulcer (bedsores)

Answer 11

• usually in-patient
• unrelieved pressure usually between bone and support surfaces
• risks: elderly, poor nutrition, confusion, sensory loss
• sacrum, heel and greater trochanter most common
• pressure relief, pressure reducing products include wheelchair cushions, mattresses

Question 12

Prevent ulcers

Answer 12

• education
• pressure relief products and turning
• nutrition
• proper skin care (ointments and barriers)

Question 13

Debridement

Answer 13

Purpose is to Remove necrotic tissue and reduce bacterial growth, removal of debris and tissue until only normal, soft, and well vascularized tissue is present
Selective
Nonselective
Autolytic

Question 14

Selective debridement

Answer 14

Use scalpel, pick ups, and scissors

Physicians and others per state statutes

Question 15

Non selective

Answer 15

Whirlpool, wet dry dressing , surgery, pulsavac

Question 16

Autolytic

Answer 16

By the body, very slow and not indicated when aggressive debridement is warranted

Question 17

Wound evaluation

Answer 17

• Complete History (diabetic? Wounds in past and how did they heal?)
• Take vitals
• Overall skin integrity (fragility of skin)
• Sensation and pain
• Vascular status
• Edema present
• Mobility

Question 18

Wound cleansing

Answer 18

• Purpose: remove foreign bodies, debris, excess exudate, and dressing residue; reduce bacterial count; and rehydrate wound.
• Should be done at each dressing change

Question 19

Whirlpool baths/soaks

Answer 19

Loosen remove contaminants and necrotic tissue

-cross contamination, damage to tissues from water pressure

Question 20

Scrubbing/ swabbing

Answer 20

• remove gross contamination, prevent tattooing, use on periwound tissues
• damage to tissues from pressure, shedding of cotton fibers, redistributed bacteria over wound bed

Question 21

Irrigation

Answer 21

• remove contaminants, exudate, loose tissue and dressing residue, reduce bacterial colonization
• splash back, exposure to disease

Question 22

Sterile .9% saline solution

Answer 22

Non toxic, isotonic, no antiseptic action, no damage

Question 23

Tap water

Answer 23

-hypotonic, can cause cells to swell, pain with contact, does not appear to damage tissues

Question 24

Antiseptics

Answer 24

Antimicrobial action in decolonization of bacteria, inactivated by body fluids, cytotoxic to tissues, hinders healing

Question 25

Wound dressings

Answer 25

Purposes: promote healing, reduce pain, prevent contamination and infection, contain exudate, and provide mechanical protection.

Question 26

Dry gauze

Answer 26

- secondary dressing - accessible most common - dn promote moist environment, no physical barrier, frequent changes

Question 27

Paraffin/impregnated gauze

Answer 27

- puncture and cavity wounds - moist environment, protective barrier - frequent changes, uses of secondary dressing

Question 28

Skin Tapes

Answer 28

- superficial, linear lacerations - painless, quick, lower rates of infection and tissue damage - use only on low tension wounds

Question 29

Foam

Answer 29

Partial and full thickness wounds, heavy exudate - impermeable to bacteria, super absorbent, stay in place 3-7 days - no visual assessment of wound, use of secondary dressing

Question 30

Film

Answer 30

- superficial and partial thickness wounds - impermeable to bacteria, resist tear, visual assessment of wound, stay in place 1-7 days - non absorbent, adhesive surface can damage wound upon removal

Question 31

Hydrogel

Answer 31

Partial and full thickness wounds - impermeable to bacteria, super absorbent, partial assessment of wound 1-3 - use of secondary dressing, capable of supporting microorganism growth in absorbed drainage

Question 32

Hydrocolloid

Answer 32

Superficial partial and full thickness wounds - impermeable to bacteria, waterproof, up to 7 - no visual assessment of wound, removal may be difficult after 7 days

Question 33

Dermal adhesives

Answer 33

- early approximated surgical incisions and simple traumatic lacerations - less application time and pain, full strength in minutes - use only in low tension wounds may violate State practice acts