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Wound Care WCC
WCC exam
| Question | Answer |
|---|---|
| The skin is comprised of two layers, the epidermis and the dermis. Each layer consists of numerous cells. Which cells would you find in the dermis? | Macrophage, Fibroblast, Mast Cells |
| The dermis is made up of proteins, i.e. collagen and elastin. These two proteins are responsible for: | Giving skin tensile strength and providing the skin with elastic recoil |
| Red blood cells also known as erythrocytes are the most abundant cells in the blood. They account for 40-45% of the blood. The % of blood made up of RBC's is measured by a lab known as | Hematocrit |
| Stem cells produce a protein that makes red blood cells look red and gives them the ability to transport oxygen. What is this protein called? | Hemoglobin |
| WBC produce protein that makes RBC look red and gives them the ability to transport oxygen. What is this protein called? | Neutrophil |
| Assessment and documentation of a skin lesion should include location, sensation, duration, morphology, and configuration. What is configuration? | shape or outline |
| Dermatomal corresponding to nerve root distribution is | zosteriform |
| To assess pain with non-verbal cognitively impaired patients or non-English speaking patients, it is recommended to use | Wong Baker Faces Pain rating scale |
| Pain quantification would include: | intensity, location, quality, onset, duration, aggravating, alleviating factors |
| T/F- Staging is used for Pressure Ulcers ONLY | True |
| T/F- Wound assessments should be documented every four weeks at a minimum | False---Should be documented weekly! |
| T/F- A stage III pressure ulcer is partial thickness skin loss involving the epidermis, dermis or both. | False |
| T/F-Painful blood filled blister located on the heel would be considered unstageable. | False---Suspected deep tissue injury |
| T/F- As we age, the basement membrane between the dermis and epidermis flattens out. | True |
| Circular, free fluid filled, greater than 1 cm | Bulla |
| Superficial, solid, less than 1 cm, color varies. | Papule |
| Circular, free fluid filled, up to 1 cm | Vesicle |
| Linear erosion; destruction of skin by mechanical means | Excoriation |
| Loss of epidermis; caused by exposure to body fluids | Denuded |
| Smaller red macules located adjacent to the body of main lesions | Satellite lesions |
| Change in color of skin, circular flat discoloration, less than 1 cm | Macule |
| Firm, edematous plaque, infiltration of dermis, may last few hours | Wheal |
| Bottom of foot. | Plantar |
| Inner aspect of ankle | medial |
| Outer apect of ankle | Lateral |
| Tunneling and undermining is caused by | shear |
| A____ is part of the wound team and can assess for cognitive deficits and work to improve. | Speech Therapist |
| When a patient is treated w/out his/her consent, whether the treatment is life saving or not is called | Medical Battery |
| A non-adherent patient that does not comply or adapt to intervention deemed necessary by the health care provider. If a patient is consistently non-adherent what must be done before discontinuing care? | Counseling, discuss consequences, document every instance of non-adherence |
| The provider relationship is terminated without making reasonable arrangements with an appropriate person so that appropriate care by others can be continued. This is called | patient abandonment |
| One of the problems with Evidence based practice in wound care is there is | limited wound care research available that supports efficacy and safety |
| The Dermis contains an important cell called the fibroblast. What does a fibroblast produce? | Collagen and Elastin |
| When sweat and sebum mix on the skin they produce | Acid Mantle |
| What is the pH of the skin? | 4- 5.5 |
| A fullthickness wound would include skin loss through the epidermis, dermis into the subcutaneous and possible bone, muscle and tendon. This type of wound will move through four overlapping phases of healing. These phases are: | Hemostasis, inflammatory, proliferative, maturation |
| During the Hemostasis phase of full thickness healing, the whole cascade of healing begins. At this time the platelets from the damaged blood vessels will come into contact with collagen and damaged tissue. This results in: | Activation and aggregation |
| What occurs during platelet activation and aggregation? | Shape changes, adhesiveness, clumping, release of growth factors. |
| The main function of the Hemostasis phase of wound healing is | coagulation and secretion of growth factor |
| The main function of inflammatory phase is | remove debris |
| During what phase of full thickness wound healing does the wound remodel and increase tensile strength? | maturation |
| What are the 3 types of wound closure? | Primary, secondary, tertiary |
| With primary intention, wound edges are brought together and held in place by mechanical means. Within how many hours will epithelial resurfacing take place? | 24-48 hours |
| A patient has a pressure ulcer on their coccyx. In knowing about types of wound closure, how would you expect this wound to close? | secondary intention |
| ___ can increase the work load of the heart, decrease chest expansion and compromise tissue oxygenation. | Obesity |
| An overweight person weighs too much, while an obese patient has too much body fat. Fat or adipose tissue is less tolerant of ischemia and hypoxia, and is | poorly vascularized |
| The process of delivering a fluid or cleansing solution to the wound by means of specific mechanical force is cleaning the wound. _____ is the preferred cleansing agent | Normal saline |
| Commercial cleansers contain surface active agents known as | surfactants |
| Your patient, with a very large sacral wound that has 50% necrotic tissue and tendon exposed. The wound is infected, and needs to be debrided. What would be the best choice of debriedement? | sharps |
| What are the 5 types of debridement? | Autolytic, mechanical, sharps, bio-surgical, enzymatic |
| Presence of ____ in the wound creates a burden on the wound healing process by competing for oxygen and nutrients in the wound bed (bio burden) | bacteria |
| A common bacteria found frequently around hydro/respiratory equipment is | pseudomonas |
| There is no one specific lab test that indicates the dx of osteomyelitis; however, 3 labs done together with positive results could be indicative of osteomyelitis. What 3 labs? | CBC, WBC, Pre Albumin |
| If giving pain medication parenterally, the clinician should wait ______, when given orally, the clinician should wait _____. | 15-30 min, 1 hour |
| Presence of replicating microorganisms which do not cause injury to the host is | colonization |
| Signs and symptoms of a wound infection would include | induration, erythema, pain |
| If epiboly occurs a wound margins wound healing will | stop |
| What would be a COMPLETE wound order? | Location, frequency, barrier, primary, secondary, cleansing solution, secure with, duration |
| The dressings that provide an environment for autolytic debridement are | alginates, hydrocolloids and transparent dressings. |
| T/F--All chronic wounds are infected. | False |
| T/F--When a pressure ulcer has high levels of exudate, consider it infected. | False |
| The best method to determine whether a wound is infected is to perform a | tissue culture |
| T/F--Dressing changes 4 times a day will assist with pain reduction and prevent infection. | False |
| T/F--Safe irrigation pressures are 3-25 psi | False |
| The recommended treatment for systemic wound infection is the application of ______ or _____ along with______ | topical antiseptic or antibiotics; systemic antibiotics |
| Hydrocolloid dressings are ____ and provide ____ | occlusive; autolytic debridement |
| The Joint Commission recommends a nutritional assessment be completed within ______ of admission. | 24 hours |
| People with_____have difficulty swallowing and may experience pain while swallowing. | Dysphagia |
| Albumin measures ______ | visceral protein stores |
| Half life for Albumin is | 18-21 days |
| At risk level for Albumin is | <3.5 gm/dl |
| Pre-albumin is a more sensitive measure of visceral protein stores, providing a more current picture of protein status. What is the half life and at-risk level for Pre-albumin? | 1-2 days, <16 mg/dl |
| Transferrin is another laboratory test that measures visceral protein stores, this test however is not recommended in patients who have____ | iron deficiency |
| Hemoglobin, used to monitor for anemia, is a protein that carries oxygen in the blood, and is contained in red blood cells. Normal values in a male would be___ | 14-18 gm/dl |
| Fat soluble vitamins are not excreted by the body, and remain in the liver and fat tissue until they are used. Deficiencies are rare. What are the fat soluble vitamins? | A, D, E, K |
| Vitamin A effects healing and is needed for promoting deposition of | collagen |
| C vitamins effect healing and are needed for promoting deposition of _____ and ____ function. | collagen; fibroblast |
| Water soluble vitamins are derived from water components of food, carried in the blood stream, not stored in the body and excreted in the urine. What are the water soluble vitamins? | B, C |
| ____vitamins are necessary for the production of energy from glucose, amino acids and fat, and are required for cross linking of collagen fibers in tissue rebuilding. | B |
| Patients with pernicious anemia are given what vitamin and how? | B12 injection |
| The primary goal for wound healing nutritionally is to provide adequate | calories and protein |
| Heavily draining wound. Use__ | alginate dressing |
| Dry stable intact eschar on heel. Use__ | dry dressing |
| Partial thickness friction wound on shoulder. Use__ | transparent film |
| Radiation burn. Use__ | Hydrogel |
| Contraindicated or use with silver products. | Enzymatic ointment |
| Partial thickness pressure ulcer in sacral area of incontinent patient. Use___ | Hydrocolloid |
| Fragile wound bed. Use___ | Contact layer |
| Dressing that keeps the bed the warmest. | Foam dressing |
| For pseudomonas infection use___ | Acetic acid |
| What is the risk assessment tool used for? | Predicting pressure ulcer development and determining risk level |
| Tools used to assess for pressure ulcer risk. | Norton, Braden, Norton Plus |
| What tool is used to determine pressure ulcer healing? | PUSH |
| To reduce pressure off of boney prominences what rule would you want to remember? | Rule of 30 |
| When placing a patient on a Group 2 or Air Fluidized Therapy, what is important to know? | It is not recommended for patients with unstable spine or pulmonary disease. |
| An ABI can be used to rule out significant arterial occlusion and determine the amount of compression that can safely be applied. What indicates a normal ABI reading? | >/= 1.0 |
| What causes venous leg ulcers? | Venous hypertension |
| Theories of venous ulceration include | Fibrin cuff theory, WBC trap theory, Trap hypothesis |
| Your pt has Venous Hypertension and has a hx of ulcers. She comes to you with an ulcer on the R medial malleolar area. You receive an order to obtain ABI and compress. What results would permit compression? | >/= 0.6-1.0 |
| Your pt has an ABI of 0.8. Could you compress? If so what therapeutic range? | Yes, modified @ 23mm Hg |
| What amount of compression would be considered therapeutic for venous ulcer management? | 30-40 mm Hg |
| Compression is contraindicated in what patients? | Decompensated CHF, Peripheral arterial disease, ABI</= 0.5 |
| When diagnosing arterial occlusion what is considered to be the "Gold Standard" | Angiogram |
| It has been noted that ___% or more of diabetic foot amputations are a direct result of improper footwear. | 50 |
| Diabetic footwear should be assessed for | bulges, wear patterns, wearing down on heels, worn, flattened out lining, foreighn objects, proper fit |
| Characteristics of a leg assessment for venous ulceration may reveal | irregular wound margins, heavy exudate, hemosiderin staining, medial lower leg, ruddy granular |
| Characteristics of assessment for arterial ulceration may reveal | even wound margins, deep pale wound bed, intermittent claudication, lateral malleolus, ABI 0.7 |
| Characteristics of assessment for neuropathic ulceration may reveal | even wound margins, plantar aspect foot, insensate foot, deep granular wound bed. |
| Callus formation is most commonly associated with | continued pressure |
| The most common risk factors leading to breakdown of the diabetic foot include | peripheral neuropathy, trauma, deformity |
| What offloading technique is recommended for patients with a plantar neuropathic ulcer? | total contact casting |
| Progressive foot deformity with collapsed arches and joint fractures related to neuropathy is | Charcot foot |
| In acute wound healing epithelial resurfacing takes place in | 2-3 days |
| What classification of burn is most painful? | superficial partial thickness |
| ___ is the only oral anabolic agent approved by the FDA to promote weight gain after involuntary weight loss. | Oxandrin |
| A __% loss of weight in the last three months indicates a significant decline in nutritional status. | 10% |
| For boggy heels, massage moisture barrier ointment over reddened area followed with | foam heel protectors |
| Where do pressure ulcers typically develop on people who spend a great deal of time seated? | Ischial Tuberosities and heels |
| Shallow epidermal involvement when surfaces are rubbing together is called | friction |
| Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle are not exposed is what stage? | III |
| Serum filled blister on heel is what stage? | II |
| Coccyx, with 90% yellow firmly adherent slough and bone in the wound bed. | IV |
| Pressure area to sacrum that is 100% covered with black eschar is what stage? | Unstageable |
| R trochanter that is red, non-blanchable, boggy and the skin is still intact. | Stage 1 |
| Full thickness wound that occurs in wrinkle or furrow skin. Both epidermis and dermis are pulled apart as if an incision has been made,exposing tissue below. What category skin tear? | Category 1A |
| Occurs when a patient develops a tissue reaction in a previously irradiated filed following the administration of a chemotherapeutic agent. | Radiation recall |
| Incision closed by primary intention, the incision is usually covered with a sterile dressing for how long? | 24-48 hours |
| Pyoderma Gangrenosum is a rare inflammatory disease of unknown etiology with painful skin ulcers. Clinically their appearance is | irregular, jagged, raised wound edges that are violet or bluish in color. |
| Sickle cell ulcerations are chronic usually appearing on the leg, and recurrence rates are high. A laboratory test used for Diagnosing Sickle cell ulcerations is | Hemoglobin electrophoresis |
| A fistula is an abnormal passage between two or more structures or spaces. Contributing factors to fistula formation are | Inflammatory bowel disease, cancer, diverticulitis, sepsis, malnutrition |
| Fistulas drain bile, stool, or urine. This can pose a problem for the peri fistular area. What could you use that would protect the peri fistular area? | pouches, skin barriers, petroleum/ zinc based ointments. |
| If intrinsic means "located within", what does extrinisic mean? | external |
| A palliative care patient suddenly developed a dark pear shaped ulcer on the sacrum with irregular borders that progressed rapidly in size. This suggest the pt has: | A Kennedy Terminal Ulcer |
| Upon assessment of a wound it observed to have a nodular cauliflower shaped tissue in the wound bed with heavy seropurulent exudate accompanied by a pungent odor. This suggest: | fungating wound |
| A patient presents with multiple painful necrotic lesions located on her legs and torso. Labs results elevated serum calcium, phosphate, BUN and creatinine. This suggest: | Calciphylaxis |
| An indication for HBO (hyperbaric oxygen therapy) is | gas gangrene |
| What important information should the wound care team forward to discharge planner upon a pts discharge? | Wound treatment and Emergency contact phone number. |
| One time only "snap shot" of the number of cases at a given time is | prevalence |
| Pt admitted to ER c/o abdominal pain. Upon exam the lower right quad of the abd appears red, swollen, and hot to touch. The skin becomes blue gray, fluid filled blisters. This is symptoms of | necrotizing fascitis |
| Odor in wounds is caused by | anaerobic bacteria, necrotic tissue, saturated dressing |
| A pt dx with colon cancer develops candida rash under her breast. The most appropriate tx is | Miconazole |
| Due to increased epdiermal-to -dermal cohesion, deficient stratum corneum and impaired thermoregulation neonates are at high risk for | epdiermal stripping |
| A 2 year old child has a stage II pressure ulcer on his elbow. Use what treatment? | Apply liquid barrier film to peri-wound and apply transparent dressing. |
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