Wound Care Module 1

Question 1

PART 1: REDUCE OF ELIMINATION CAUSE

Answer 1

PART 1: REDUCE OF ELIMINATION CAUSE

Question 2

What are the 5 parts of a wound care assessment?

Answer 2

• Assess patient risk using the Braden Scale
• Make adjustments for correct bed and chair positions
• Determine appropriate surfaces for pressure reduction
• Reduce the effects of gravity
• Understand the importance of oxygenation and blood flow

Question 3

What is used to assess risk for pressure ulcer risk?

Answer 3

Braden Scale

Question 4

What 6 factors are scored with the Braden Scale?

Answer 4

• Sensory Perception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction and Shear

Question 5

• What is the highest Braden Scale score?

- A score lower than ____ puts patients at risk for pressure ulcers.

Answer 5

• 28

- 18

Question 6

What is the correct bed positioning?

Answer 6

knees and hips slightly flexed

Question 7

Pressure Reduction Surfaces are categorized as _________ Pressure or _________ Pressure.

Answer 7

localized or distributed

Question 8

• If the patient is in bed, change position at least every ___ hours.
• If the patient is in a chair, change position at least every ____. Instruct your patient to shift their weight every ___ minutes if they are able.

Answer 8

• 2 hours

- hour, 15 minutes

Question 9

What causes a diabetic foot ulcer?

Answer 9

• Neuropathy leading to decrease/loss of sensation.
• Difficulty discovering an ulcer.
• Cant feel pressure being exerted on foot.
• May go unnoticed until ulcer already present.

Question 10

• What is off-loading?

- Why is it important?

Answer 10

• Off-loading is the act of relieving pressure from plantar tissues. It is the key to pressure ulcer treatment and prevention.
• The goal of off-loading is to control, limit, or remove all intrinsic and extrinsic factors that increase plantar pressures.

Question 11

What non-surgical methods can be used for treatment of ulcers?

Answer 11

• Contact Casting
• Orthotics
• Cast Walkers
• Therapeutic Footwear
• Dressings

Question 12

What is the most effective method of reducing edema?

Answer 12

Elevate the leg and allow gravity to drain fluid from the limb.

Question 13

• ___________ bandages are useful when a patient can’t elevate their affected limbs. They’re also helpful for times when a patient is on his feet.
• What must be taken before application of this?

Answer 13

• Compression

- ABI Index

Question 14

What are the benefits of compression therapy?

Answer 14

• Improves rate of ulcer healing
• Reduces the incidences of recurrence
• Prolongs the time to the first recurrence
• Improves lymphatic drainage
• Reduces superficial venous pressure
• Improves blood flow velocity through unoccludeddeep and superficial veins
• Reduces reflux in the deep veins

Question 15

What 2 things are used for compression therapy?

Answer 15

Rigid and Elastic Compression

Question 16

What is the first goal in the treatment of an ulcer?

Answer 16

Reestablish arterial flow (revascularization)

Question 17

What are 3 surgical methods for revascularization?

Answer 17

• Arterial bypass
• Angioplasty
• Stents

Question 18

What are the causes of poor blood flow?

Answer 18

• Pressure
• Arterial occlusion
• Vasoconstriction
• Peripheral vascular disease
• Atherosclerosis

Question 19

What causes lower oxygenation levels?

Answer 19

• Inadequate oxygen intake
• Hypothermia or hyperthermia
• Anemia
• Alkalemia
• Chronic obstructive pulmonary disease

Question 20

PART 2: NUTRITION AND PATIENT SUPPORT

Answer 20

PART 2: NUTRITION AND PATIENT SUPPORT

Question 21

Thorough nutrition therapy should include what 3 things?

Answer 21

• A nutritional assessment
• Design of an individualized treatment plan
• Periodic monitoring to evaluate the plan’s effectiveness

Question 22

A treatment plan should always begin with the least _______/_______ approach and should incorporate what 2 things?

Answer 22

-invasive/costly

• Adequate calories and proteins to promote anabolism and the growth of new tissue.
• A diet that fits the individual patient needs.

Question 23

A complete nutritional assessment includes what 5 things?

Answer 23

• body measurements
• evaluation of lab results
• physical examination
• dietary interview

Question 24

The outcome of a nutritional assessment provides the ability to do what?

Answer 24

• Determine pt nutrient needs.
• Evaluate adequacy/appropriateness of current diet.
• Recommend changes.

Question 25

- Malnutrition occurs in ___% of non-surgical patients. - Malnutrition occurs in ___-___% of surgical patients. - Malnutrition occurs in ___-___% of older patients.

Answer 25

- 30% - 45%-57% - 53%-74%

Question 26

What are the physical signs of dehydration?

Answer 26

- Dry skin - Cracked lips - Thirst - Poor skin turgor - Fever - Appetite loss - Nausea - Dizziness - Increased confusion

Question 27

What are the clinical signs of dehydration?

Answer 27

- Increased laboratory values for the following: serum creatinine, hematocrit, blood urea nitrogen, potassium, chloride, osmolarity, sodium - Decreased blood pressure - Increased pulse rate - Constipation - Concentrated urine

Question 28

What are 3 ways to prevent dehydration?

Answer 28

- Keep water or other beverages at the bedside so that they are easily accessible. - Offer water at least every two hours if the patient doesn’t consume fluids on his or her own. - Intravenous therapy when necessary.

Question 29

PART 3: PREPARE FOR WOUND HEALING

Answer 29

PART 3: PREPARE FOR WOUND HEALING

Question 30

________ = A group of organisms living together in or on the body prior to tissue invasion not causing infection.

Answer 30

Colonization

Question 31

_________ = Invasion of tissues by microorganisms resulting in systemic reaction (fever, edema, erythema, etc.).

Answer 31

Infection

Question 32

What are the 3 things used in the detection of infection?

Answer 32

- Local and systemic symptoms - Contamination and bacterial balance - Clinical abnormalities

Question 33

What are the local symptoms of infection?

Answer 33

- Erythema - Edema - Drainage - Tissue around wound with induration - Tenderness - Warmth - Crepitus

Question 34

What are the systemic symptoms of infection?

Answer 34

- Fever - Leukocytosis - Confusion - Tachycardia - Hypotension - Malaise

Question 35

Wounds with bacterial counts of ___k organisms per gram of tissue or less are considered contaminated.

Answer 35

100k

Question 36

What are 3 culturing methods?

Answer 36

- Surface Swab Culturing - Needle Aspiration - Tissue Biopsy

Question 37

What is debridement?

Answer 37

Debridement is the removal of necrotic tissue from the wound area.

Question 38

What are some types of debridement?

Answer 38

- Sharp Debridement - Chemical/Enzymatic - Autolytic - Mechanical

Question 39

What are the goals of wound cleansing?

Answer 39

- To remove debris that support bacterial growth and delay healing. - To use as little chemical or mechanical force as possible. - To protect healthy granulation tissue. - To balance pH and moisture. - To minimize odor and pain. - To separate necrotic tissue from healthy tissue.

Question 40

What 3 types of solutions are used for wound cleaning?

Answer 40

- Saline Solution - Commercial Wound Cleaners - Antiseptic Solution

Question 41

You must limit the use of antiseptic solutions to between __-__ days.

Answer 41

3-7