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Wound Care WCC

WCC exam

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.
Created by: excbchic