Wound Exam

Question 1

when should patients be assessed for the potential development of wounds?

Answer 1

upon admission to a HCF - because if a pt gets a pressure wound during admission this can leads to negative billing effects

Question 2

which five items must be sterile for sterile techniques? which item must also be sterile for clean techniques?

Answer 2

• equipment, gloves, field, dressings, and instruments

- instruments must be sterile for clean techniques

Question 3

when are sterile techniques appropriate (3)

Answer 3

1. pts at high risk of infection
2. invasive procedures
3. sharp wound debridement

Question 4

when (1) and where (2) are clean techniques appropriate

Answer 4

1. routine wound care
2. subacute care
3. home care

Question 5

describe an appropriate sterile procedure (6)

Answer 5

1. handwashing
2. maintain gloved hands above waist in line of sight
3. touch wound with only sterile items
4. open wound only prior to use
5. clean technique to apply noncontact bandages
6. discard sterile supplies if contaminated

Question 6

describe an appropriate clean procedure (5)

Answer 6

1. handwashing
2. used clean gloves on a clean field
3. only use sterile instruments
4. prevent supply contamination
5. minimize dressing handling by only touching the outer edges

Question 7

describe an appropriate dressing removal protocol (3)

Answer 7

1. gently lift barrier from surrounding skin
2. note amount, type, color, and odor of dressing
3. discard dressing and gloves according to facility protocol

Question 8

what are classifications of wounds we must consider prior to treatment

Answer 8

aterial, venous, neuropathic, pressure, and burns that can be superficial/partial/deep or red/yellow/black

Question 9

what are the five ways we describe a wound

Answer 9

1. classification
2. location
3. size and depth
4. wound base and edges
5. exudate

Question 10

what is a slough

Answer 10

yellow fibrinous tissue that contains fibrin, pus, and proteinaceous material

Question 11

what is an eschar

Answer 11

necrotic tissue that is leathery and dry

Question 12

how do you describe the location of a wound

Answer 12

in relation to bony landmarks

Question 13

how do you describe the size and depth of a wound

Answer 13

LxWxD
tunneling and undermining (o’clock)
fistula
sinus tract

Question 14

how do you describe the wound base and edges

Answer 14

tissue color, type, and anatomical structures involved (such as fat, BVs, bone, fascia, tendons, etc)

Question 15

what are the five types of exudate

Answer 15

1. sanguineous
2. serosanguinous
3. serous
4. seropurulent
5. purulent

Question 16

what does sanguineous exudate indicate

Answer 16

new blood vessel growth or disruption of local circulation

Question 17

what does serosanguineous exudate indicate

Answer 17

normal during inflammatory and proliferative phases of healing

Question 18

what does serous exudate indicate

Answer 18

normal during inflammatory and proliferative phases of healing

Question 19

what does seropurulent exudate look like and what does it indicate

Answer 19

cloudy, yellow/tan, thin, watery

may be the first sign of impending wound infection

Question 20

what does purulent exudate look like and what does it indicate

Answer 20

yellow, tan, green, thick, opaque, odorous

signals wound infection

Question 21

on what scale can you describe exudate

Answer 21

none
scant
minimal (<33%)
moderate (33-67%)
copious (>67%)

Question 22

describe the pitting scale

Answer 22

1+ 0-1/4 in
2+ 1/4-1/2 in
3+ 1/2-1 in
4+ >1 in

Question 23

describe the capillary refill test

Answer 23

light pressure over each digit for 2-3 seconds, in arterial disease digits will remain blanched >3s

Question 24

how do you perform the rubor of dependency test

Answer 24

pt is supine and limb elevated to 45 degrees for about 1 minute

Question 25

what do you look for in rubor of dependency test when the leg is elevated?

Answer 25

the foot will begin to blanch in the presence of arterial insufficiency when elevated according to the procedure

Question 26

what do you look for in the rubor of dependency test when the leg is returned to rest

Answer 26

normal - foot should return to pink within 15s

arterial disease - foot will take >30s to return to color and will be dark red

Question 27

what is the venous filling time test

Answer 27

measure of venous integrity in a normal venous system (valvular problems could bias the test)

leg elevated to 45 for a minute then returned to rest

Question 28

what is a normal and abnormal venous filling time test

Answer 28

normal: 15 seconds for veins to refill

arterial disease: >30 s refill

Question 29

what is the ABI and what is a normal value

Answer 29

ankle brachial index - use of a BP cuff and doppler probe to determine systolic BP at brachial and dorsalis pedis arteries (normal approx 1.0-1.2 mmHg)

Question 30

an individual has normal sensation when _____ monofilament is felt.

an individual has protective sensation when _____ monofilament is felt

Answer 30

4.17 and 5.07