Wound Care Modules

Question 1

Components of Braden Scale

Answer 1

1. Sensory Perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction and Shear

Question 2

Braden scale scoring

Answer 2

High: 28

18 or lower: risk of pressure ulcers

Question 3

Repositioning in bed

Answer 3

change position every 2 hours

Question 4

Repositioning in chair

Answer 4

change position every hour

shift weight every 15 min if possible

Question 5

Pressure reduction surfaces

Answer 5

1. Redistribute
2. Inner spring mattress
3. foam core mattress
4. thick foam overlay (eggcrate)
5. low air loss overly
6. low air loss replacement
7. alternating air cell

Question 6

Goal for offloading diabetic foot ulcers

Answer 6

control, limit or remove all intrinsic and extrinsic factors that increase plantar pressures.

Question 7

Diabetic foot ulcers:

Non-surgical trx

Answer 7

contact casting, orthotics, cast walkers, therapeutic footwear

Question 8

Diabetic foot ulcers:

curative surgery

Answer 8

1. exostectomy
2. digital arthroplasty
3. bone and joint resection
4. partial calcanectomy

Question 9

Venous stasis ulcer treatment

Answer 9

1. elevate the leg

2. compression therapy (rigid or elastic) when you can’t elevate

Question 10

Benefits of compression therapy

Answer 10

1. improves rate as ulcer healing
2. reduces incidences of recurrence
3. prolongs the time to the first recurrence
4. improves lymphatic drainage
5. reduces superficial venous pressure
6. improves blood flow velocity through unoccluded deep and superficial veins
7. reduces reflux in the deep veins

Question 11

Arterial Ulcers:

Goal of treatment

Answer 11

revascularization procedures

Question 12

Arterial Ulcers:

Revascularization procedures

Answer 12

1. arterial bypass
2. angioplasty
3. stents

Question 13

Arterial Ulcers:

Arterial bypass

Answer 13

most common

graft may be autogenous or synthetic

Question 14

Arterial Ulcers:

Angioplasty

Answer 14

catheter with balloon inserted into artery portion with plaque.
balloon crushes plaque against arterial wall

Question 15

Arterial Ulcers:

Stents

Answer 15

holds the artery open

Question 16

Perfusion:

effects of impaired blood flow and tissue perfusion

Answer 16

1. ischemia

2. affects scarring, and can lead to increased risk of infection

Question 17

Nutritional Assessment components

Answer 17

1. Nutrition
2. Hydration
3. Education

Question 18

Nutritional Assessment:

Protein

Answer 18

1. Initial assessment provides baseline data about a patient’s nutritional status
2. Subsequent assessments reflect changes in status and effects of interventions

Question 19

Nutritional Assessment:

Nitrogen-balance study

Answer 19

1. Nitrogen input determined by eval of 24 hour intake of nitrogen
2. Nitrogen output from 24 hr urine collection
3. Nitrogen input minus output (want=0)
4. Retained nitrogen available for protein synthesis

Question 20

Nutritional Assessment:

physical signs of dehydration

Answer 20

1. dry skin
2. cracked lips
3. thirst
4. poor skin turgor
5. fever
6. appetite loss
7. nausea
8. dizziness
9. increased confusion

Question 21

Nutritional Assessment:

clinical signs of dehydration

Answer 21

1. Increased lab values for serum creatinine, HCT, BUN, K+, Cl-, osmolarity, and Na+
2. Decreased BP
3. increased pulse rate
4. constipation
5. concentrated urine

Question 22

Pressure ulcer Do’s and Don’ts

Answer 22

Do:

1. change position every 2 hours
2. check skin for signs of pressure ulcers 2/day
3. use mirror to check difficult areas
4. follow HEP
5. well balanced diet, hydrate, maintain recommended weight

Don’ts:

1. use commercial soaps that dry skin
2. sleep on wrinkled bed sheet or tuck corners tight into EOB

Question 23

Colonization:

Answer 23

Group of organisms living together in or on the body prior to tissue invasion not causing infection

Question 24

Infection:

Answer 24

invasion of tissues by microorganisms resulting in systemic reaction

Question 25

Local signs of infection

Answer 25

1. edema 2. erythema 3. drainage 4. warmth 5. tenderness 6. crepitus

Question 26

Systemic signs of infection

Answer 26

1. fever 2. leukocytosis 3. confusion 4. tachycardia 5. HTN 6. malaise

Question 27

autolytic debridement

Answer 27

allows body to lysis necrotic tissue using its own moisture to dissolve tissue. (don't do if infected)

Question 28

chemical debridement

Answer 28

enzymes applied topically to necrotic tissue. digests. allows for moist wound healing

Question 29

mechanical debridement

Answer 29

use of physical forces to remove necrotic tissue wet-to-dry dressings wound irrigation whirlpool

Question 30

sharp debridement

Answer 30

removing necrotic tissue with cutting tool

Question 31

sharp debridement: | conservative vs surgical

Answer 31

conservative: removes necrotic tissue only surgical: removes necrotic and healthy tissue

Question 32

Cleansing: | normal saline

Answer 32

- provides a moist environment - promotes granulation tissue formation - causes minimal fluid shifts in healthy cells

Question 33

Cleansing: | commercial wound cleansers

Answer 33

used to remove containments, foreign debris, and exudate from wound surface or used to irrigate deep cavity wound

Question 34

Cleansing: | antiseptic solutions

Answer 34

may damage tissue and delay healing

Question 35

Wound environment: | Moist wound bed provides

Answer 35

1. communication amongst cells 2. communication with growth factors 3. construction of collagen 4. migration of new epithelium

Question 36

Wound environment: | Benefit for moist wound bed

Answer 36

1. enhances epidermal migration 2. promotes new blood vessel growth 3. promotes development of collagen/CT

Question 37

Wound environment: | Dry wound bed effects

Answer 37

1. WBCs can't fight infection 2. enzymes can't break down dead material 3. macrophages can't carry away debris 4. epithelial cells burrow underneath wound bed preventing re-epitheliazation

Question 38

Components of a wound environment

Answer 38

Moist environment | protection from heat and cold

Question 39

Wound environment: | heat

Answer 39

- some benefit, too much detriment. - excessive heat can cause increase in bacteria - increase of temp combined with pressure =susceptibility to injury

Question 40

Wound environment: | Cold

Answer 40

- may cause hypoxia - may have AE on immune function - decreased subcut O2

Question 41

Considerations for packing

Answer 41

1. wound size 2. depth 3. drainage 4. type of dressing 5. solution to maintain moist environment

Question 42

Impact of frequency of dressing changes:

Answer 42

1. prevent washing away of growth factors and other beneficial proteins 2. protect fragile wound bed from damage

Question 43

Most susceptible areas for pressure ulcers

Answer 43

sacrum and coccyx (65%) trochanter (9%) heel and ankle (15%)

Question 44

Most common areas for venous ulcers

Answer 44

anywhere between ankle and midcalf. medial aspect above malleolus most common

Question 45

Venous ulcer appearance

Answer 45

shaggy, irregular borders. usually shallow

Question 46

Venous ulcer pathophysiology

Answer 46

1. vein becomes dilated 2. blood vessel congestion 3. fluid leaks out and congests immediate tissue area 4. tissue becomes poorly perfused, dies, ulcer results

Question 47

Arterial ulcer pathophysiology

Answer 47

caused by damaged arteries that decrease blood flow to tissue leads to cell death PVD, DM, smoking

Question 48

Arterial ulcer assessment

Answer 48

- weak or absent pulse - absence of leg hair - thickened nails - pain - cold feet

Question 49

Ulcers: | minimal drainage, often occurs on the toes or dorsum of the foot, and is accompanied by a weak or absent pulse?

Answer 49

arterial

Question 50

Ulcers: | heavy drainage, irregular wound borders, and often results in hemosiderin stains around the lower leg/ankle?

Answer 50

venous ulcers

Question 51

Microscopic biochemical environment

Answer 51

metabolic control, nutritional status, immune status, presence of inflammation, and tissue perfusion

Question 52

Macroscopic biochemical environment

Answer 52

levels of tissue proteases, high levels of cytokines, low levels of growth factors, tissue hypoxia, decreased proliferative capacity of the key cells, increased levels and types of bacteria.