Integumentary

Question 1

Autolytic

Answer 1

natural debridement which is promoted by moisture-retaining dressing (selective)

Question 2

Autolytic - indication

Answer 2

Anticoagulant therapy
Cannot tolerate other forms
Medically stable

Question 3

autolytic - contra

Answer 3

Infection
Immunosuppressed
Dry, gangrene or dry ischemic

Question 4

Enzymatic

Answer 4

chemical debridement, selective, topical agent placed on tissue that liquifies necrotic tissue

Question 5

enzymatic - indication

Answer 5

Moist necrotic wounds
Eschar after cross-hatching
Homebound individuals
Cannot tolerate surgical option

Question 6

enzymatic - contraindication

Answer 6

Ischemic wound
Dry gangrene
Clean, granulated, healing wounds

Question 7

Mechanical

Answer 7

non-selective, removes tissue that is non-viable or infected by physical forces. Wet to dry gauze dressing, pulsatile lavage with suction, and may remove healthy tissue too

Question 8

mechanical - indication

Answer 8

Moist necrotic wound bed or foreign material present

Question 9

mechanical - contraindication

Answer 9

Clean, granulated wound

Question 10

Sharp

Answer 10

selective method, sterile instruments used (scalpel, scissors, forceps, silver nitrate) removes necrotic wound without anesthesia and little or no bleeding of the viable, healthy tissue

Question 11

sharp - indication

Answer 11

Excise leathery eschar
Excise moist necrotic tissue
Removal of biofilm

Question 12

sharp - contraindication

Answer 12

Clean wound
Advanced cellulitis
Anticoagulant therapy

Question 13

Surgical

Answer 13

selective, deep stage 3&4 or complicated pressure ulcer, sterile instruments (scalpel, scissors, forceps, hemostat, silver nitrate) in the OR under anesthesia.
Necrotic tissue + some healthy tissue may be removed

Question 14

surgical - indication

Answer 14

Advanced cellulitis
Immunocompromised
Life-threatening infection
Clean wounds as a preliminary to delayed primary closure

Question 15

surgical - contraindication

Answer 15

Cardiac, pulmonary disease
Diabetes
Individual severely ill and near end of life
Cannot improve QOL

Question 16

Biologic

Answer 16

maggots debride nonviable tissue (selective)

Question 17

biologic - indication

Answer 17

Cannot tolerate any other form
Any non-healing necrotic wound, medically stable

Question 18

biologic - contraindication

Answer 18

Increased stress about it
Pain increases
Poor perfusion

Question 19

Transparent films

Answer 19

clear, adhesive, semipermeable membrane, permeable to O2 but NOT bacteria/water/contaminants in external environment

Question 20

transparent films indication

Answer 20

Pressure (1-2)
Autolytic debridement
Cover for hydrogel

Question 21

transparent films tips

Answer 21

Visualize wound
Do not need secondary dressing
Dressing change times vary
DO NOT use with infection, tracts, drainage

Question 22

Hydrocolloid

Answer 22

adhesive wafer, has absorptive quality to handle wound exudate…..changes to gel

Question 23

Hydrocolloid indication

Answer 23

Autolytic debridement
Mild exudate
Maintains moist env.
Non-adhesive, conforms, minimal pain complaints

Question 24

Hydrocolloid tips

Answer 24

Will have an odor and yellow exudate when removed
DO NOT use with wounds that have infection or tunneling
Edges of dressing might curl, use adhesive

Question 25

Hydrogel

Answer 25

solid sheets or in gauze bandage, absorption varies

Question 26

Hydrogel indication

Answer 26

Wounds with necrosis and slough Burns Tissue damaged from radiation Sheet form used on partial-thickness ulcers

Question 27

hydrogel tips

Answer 27

Usually requires 2nd dressing to cover Not ideal for wounds with heavy drainage DO NOT use on infected ulcers Must be changed every 1-2 days Can macerate peri-wound area

Question 28

Foams

Answer 28

absorptive foam and adhesive properties to protect and insulate wound. Requires second bandage to cover/seal.

Question 29

Foams indication

Answer 29

Packing in a wound to absorb exudate Partial and full-thickness Mild to moderate exudate

Question 30

Foams tips

Answer 30

Non-adherent and conforms to wound Change when exudate is leaking or at least every 5 days (or less) Not for dry wounds

Question 31

Alginates

Answer 31

absorbent dressing derived from seaweed. Turns to gel. Requires second bandage to cover/seal.

Question 32

Alginates indication

Answer 32

Packing into a wound to absorb exudate Mod-large exudate Can be used with or without wound infection

Question 33

Alginates tips

Answer 33

Change when exudate is leaking or at least every 3 days (or less) Not recommended for light exudate wounds

Question 34

Gauze

Answer 34

absorptive and permeable to water, air. Can be used wet, moist, dry.

Question 35

gauze indication

Answer 35

All wounds – exudate/necrotic/tunnels/ infected

Question 36

gauze tips

Answer 36

Available, used as a form of mechanical debridement Filler for large wounds with tunnels Painful to remove (wet to dry), avoid placing on granulation tissue