Wound assessment-Type

Question 1

Wound description

Answer 1

1- Aetiology –> Neuropathic. arterial, neuro-ischaemic, venous ulcer
2- Location
3- Size –> Dimension and depth ( shallow or deep
4- Clinical appearance:
4.1- Wound bed ( granulation, epithelialization, slough, necrosis
4.2 Edges: Callused over, ill-defined, demarcated, well defined
4.3 Surrounding tissue (callus, macerated, fragile
5- Exudate:
5.1- Exudate amount ( Mild, moderate and high)
5.2 Exudate type ( Serous, haemo serous, purulent)
6- Infection/ pain
7-Combined with SINBD and WIFI

Question 2

Neuropathic ulcer Aetiology, location

Answer 2

• Structural deformity and altered biomechanics, plantar aspect of foot,
  Even wound margin, peri-wound callus, can be superficial or deep with sinus formation
  painless
  Palpable pulses

Question 3

Arterial ulcer Aetiology, location and characteristics

Answer 3

Thickening and reduced elasticity of arterial walls, located in ID spaces, IPJS, medial and lateral border of the foot
Characteristics:
demarcated edge
necrotic tissue
pale base
no callus
painful and absent of pedal pulses

Question 4

Arterial ulcer indication fro referral

Answer 4

None healing foot ulcer
Absence of pedal pulses
Infection not responding to treatment

Question 5

Pressure ulcer

Answer 5

• External pressure causes local ischemia cellular death and tissue damage- Usually affects elderly
  Patients can be hospital-acquired

Location: Bony prominences- Calcaneus, 1st and 5th MPJs
Malleoli
Characteristics:
None blanch-able erythema
Skin break down
Superficial or deep

Question 6

Heel pressure ulcer consideration

Answer 6

Air mattress
Restin AFO
Mobilized patient
Heel lift boot
Herbst cradle

Question 7

Foot ulcer holistic management?

Answer 7

• Dressings
  -Offloading
  -Manage infection
  -Address other contributing factors such as systematic disease
  -Patient education and compliance

Question 9

function of dressing

Answer 9

Haemostasis
Protection
Support
Absorption
Actively debride, controls infection, and promotes healing

Question 10

Different wound dressing and the properties

Answer 10

• Iodine: Antimicrobial property ( Inadine)
  -Silver: Broad spectrum antimicrobial property ( Acticoat)
  -Foams: Exudate control ( Mepilex)
  -Urgo start: none infected neuro ischaemic wound- twice healing faster
  -Semi-permeable films:
  Transparent adhesive film, superficial and low exudating wounds- Opsite
  -Hydrocolloids: occlusive, increase maceration, used for uninfected low exudating wound- Promote auto lytic

Question 11

Alginate

Answer 11

• promote autolytic debridement, absorbent, primary dressing, highly exudating wounds
• Hydro fiber:
• Highly absorbent
• as a primary dressing
  Aquacel extra

Question 12

Hydrogel:

Answer 12

• Rehydrate wound bed
• Primary dressing
• Dry wound- moisture control