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WCC 2023
Jan-Feb 2023 Study Questions
| Trigger Word/ Phrase | Relevant Data |
|---|---|
| Percentage of people in the US with chronic wounds | 2% |
| Determination of authority to perform activities like sharps debridement | Medical licensure governing board |
| Definition of chronic wound | A wound that has failed to proceed through the healing process in a timely manner |
| Definition of a recalcitrant wound | Wound that has failed to respond to interventions, generally after 2-4 weeks. |
| Offense that can be charged if treatment is administered without patient consent | Medical battery |
| Preferred phrase to indicate non-compliance | Non-adherence |
| Goal for treating the non-adherent patient | Negotiating a mutual medical plan, wherein the patient understands the "why." |
| General functions of skin | Protection, prevention of fluid/ electrolyte loss, production of sebum, immunological response, production of melanin |
| Where is sebum produced? | Sebaceous glands. |
| What is the acid mantle consistent of? | Sweat and sebum |
| What governing body provides the gold standard for wound staging? | NPIAP (Ntl Pressure Injury Advisory Council.) |
| When must the notice of privacy practices be provided to the patient? | On the first visit. |
| What is the largest cause of HIPAA data breaches? | Human error |
| What is the function of the acid mantle? | Delays growth of microorganisms on the skin |
| What is the pH of the skin? | 4-6.8 (Average 5.5, slightly acidic) |
| What is a neutral pH? | 7 |
| What is the range for pH? | 1-14. |
| Is higher pH acidic or base (alkaline)? | Higher is base (alkaline) |
| What function does melanin serve? | Protects skin against ultraviolet radiation. |
| What cells protect against water loss? | Stratum Corneum |
| What does the skin produce to provide protection through antimicrobial activation? | AMPs (Antimicrobial peptides.) |
| What does the skin do to help dissipate or retain heat? | Vasodilation = expansion of blood vessels to cool body off) or vasoconstriction = constriction of blood vessels to warm body. |
| What does the skin use to create Vitamin D? | The sun's UV rays. |
| What impact might melanin have on Vitamin D synthesis? | It may possibly decrease it. |
| What levels are kept at normal values by the snythesis of Vitamin D in the skin? | Calcium and phosphorus in bones and blood. |
| Name the 2 layers of the skin | Epidermis (outermost) and dermis. |
| Name the 5 layers of the epidermis. | Corneum, lucidum, granulosum, spinosum, and germanativum. |
| What kind of cells is the epidermis composed of? | Stratified squamous epithelial cells (keratinocytes), melanocytes, and Langerhans and Merkel cells. |
| What do desmosomes do? | Bind keratinocytes together and provide strength to each later os the skin. |
| Where are Langerhans cells found? | Epidermis, dermis, lymph nodes, and thymus. |
| What do Langerhans cells do? | Capture, uptake, and process antigens. |
| What produces Langerhans cells? | Red bone marrow |
| What cells result in the detection of touch? | Merkel. |
| What is the function of the epidermis? | Provides barrier against toxic substances/microorganisms, prevents water loss, repels water. |
| What does the basement membrane zone (BMZ) do? | Separates epidermis from dermis and provides structural support to the skin. |
| What layer of skin is affected when a blister forms? | BMZ - fluid collects between the epidermis and dermis. |
| What affect does aging have on the skins rete ridges? | They flatten, decreasing the surface area between skin layers and reducing nutrient transfer and resistance to both shear and water loss. |
| Is the dermis vascular? | It is highly vascularized. |
| What are the two layers of the dermis? | Reticular and papillary. |
| Is the epidermis vascular? | No. It is avascular. |
| What is the largest component of the dermis? | The ECM (extra-cellular matrix.) |
| What does the ECM (extra-cellular matrix) do? | Provides structural support (framework) for cells, lubricates cells, and provides transport for nutrients and waste products |
| What is the ECM (extra- cellular matrix) composed of? | Sugars and proteins. |
| What does the reticular layer of the dermis do? | Anchors the skin to the SubQ tissue |
| What can be found in the reticular layer of the dermis? | Sweat glands, hair follicles, nerves, and blood vessels. |
| Where are the cells of the dermis produced? | In the bone marrow. |
| What are macrophages? | Scavenger cells that ingest dead tissue and cells and repair injured tissues. |
| What are mast cells? | Provide cellular defense mechanisms such as blood clotting in the healing cascade. |
| What do fibroblasts do? | Produce collagen (tensile strength) and elastin (elastic recoil). |
| What cells are the first line of defense contributing to epidermal immunity? | Langerhans |
| What are the functions of the dermis? | Nourish the epidermis, protect against mechanical injury, protect against microorganisms, sense the environment, and provide thermoregulation. |
| What is the difference between constitutive skin color a facultative skin color? | Constitutive = amount of melanin before UV exposure Facultative = amount of melanin from exposure to UV and hormones. |
| How are collagen bundles different in dark skin? | They are compact and occur in higher numbers. |
| What is dyschromia? | Hypo- or hyper-pigmentation, usually related to inflammation or injury. |
| What is keratin responsible for? | The toughness of the epidermis. |
| What is phagocytosis? | The engulfing of waste into a cell membrane. |
| What makes dark skin more prone to keloid formation? | A higher number of fibroblasts that are larger than they are in paler skin. |
| What occurs more frequently in dark skin in terms of water? | A higher rate of TEWL (transepidermal water loss.) |
| What else is subQ tissue called? | Fatty tissue. |
| What does subQ tissue do? | Stores energy, supports blood vessels and nerves, cushions the body, insulates against cold. Channels nutrients/ oxygen to the dermis via capillaries. |
| What does subQ tissue look like? | Pale yellow, waxy, globular, oily. When dry, may be tan or yellow-brown. |
| What does fascia look like? | White and shiny- if gray, non-viable. |
| What does fascia do? | Covers muscles, nerves, and blood vessels. Keeps muscle fibers in tight bundles. |
| What do healthy muscles look like? | Dark red, firm, striated. |
| What do ischemic muscles look like? | Mushy and dull red, cyanotic, or pale. |
| What does necrotic muscle look like? | Liquid, with dark brown, odorous drainage. |
| What do healthy tendons look like? | Gleaming yellow or white, shiny, fibrous. Springs back when touched. |
| What do tendons do? | Attaches muscle to bone |
| What do ligaments look like? | Ribbon-like, striated, pearly white |
| What do ligaments do? | Connect bone to bone. |
| What does hematocrit tell? | The percent of blood containing RBCs. |
| Which cells produce hemoglobin? | Stem cells. |
| What cells aid in the removal of CO2 from the body? | RBCs. |
| What cells are sticky and help create a clot? | Platelets. |
| What are the two functions of platelets? | They bind to the site of an injury (adhesion) and then bind together (activation). *Adhere- activate-aggregate* |
| List the normal lab value for RBCs | Men = 4.32-5.72 Women = 3.9-5.03 |
| Give the normal lab value for WBCs | 3400-9600 |
| List the normal lab value for Platelets | Men = 135k-317k Women = 157k-371k |
| List the normal lab value for Hemoglobin | Men = 13.2-16.6 Women = 11.6-15 |
| List the normal lab value for Hematocrit | Men = 38.3 - 48.6 Women = 35.5 - 44.9 |
| Normal range for A1C | 4-6 |
| How long does an RBC live? | Appox 120 days |
| What mineral is associated with hemoglobin? | Iron |
| What should exposed bones, tendons, or ligaments be covered with to protect them? | Hydrogel. |
| What are the first WBCs to arrive at a wound site? | Neutrophils. |
| What is the (loosely) recommended frequency for a non-high risk patient's skin? | Weekly |
| What is the recommended frequency for assessment of skin on high-risk patients? | Daily |
| How soon on admission should a skin assessment be performed? | ASAP (Within 8 hours.) |
| What impact can fluorescent light have on a skin assessment? | It can give skin a bluish tint. |
| How long should fingers be pressed into skin to assess for blanching? | 3 seconds. |
| What is pallor? | Loss of color from lack of oxygenated hemoglobin. |
| What is erythema? | Redness due to increased visibility of oxyhemoglobin. |
| What is jaundice? | Yellow undertone due to increased presence of bilirubin |
| What is carotenemia? | Yellow-orange tint caused by increased levels of carotene. |
| What is hemosiderin? | Dark pigmentation from release of hemoglobin into intercellular space after hemorrhage. |
| What temperature difference between lateralities is considered significant for inflammation? | >2-3 degrees F |
| How long should fingers be pressed into skin to assess edema? | 5 seconds |
| List the degrees of pitting in edema. | 1+ = mild (2mm depression, immediate rebound) 2+ = moderate (4mm pit, a few seconds to rebound) 3+ = severe (6 mm pit, 10-12 seconds to rebound) 4+ = very severe (8 mm pit, >20 second rebound) |
| Where should skin be pinched to assess for turgor? | Near the clavicle or the forearm. |
| What color is a violaceous ulcer? | Light violet |
| What shape is an annular ulcer? | Round or circular with central clearing |
| What shape is a circinate ulcer? | Round, circular arciform, partial circle |
| What does an iris-shaped wound look like? | A target |
| What does a gyrate ulcer look like? | It has connecting arcs. |
| What does a serpiginous wound look like? | It wanders (meanders) like a snake. |
| What cells are involved in angiogenesis? | Endothelial cells. |
| What arrangement is a confluent lesion group in? | Smaller to larger |
| What arrangement is a cleavage plan lesion group in? | Arranged along lines of skin tension. |
| What is the difference between a bulla and a vesicle? | Vesicles are up to 1 cm in size. Bulla are larger than 1 cm. |
| What do secondary lesions occur from? | Primary lesions or external forces such as scratching, trauma, infection, or the healing process. |
| What is atrophy? | The loss of substance to the skin resulting in thinning. |
| What does TEWL stand for? | Transdermal epidermic water loss. |
| What is excoriation? | Erosion or destruction of the epidermis because of mechanical forces like abrasions or scratching. |
| What is telangiectasia? | Permanent dilation of of superficial blood vessels. |
| What is purpura? | Reddish-purple skin lesions that result from bleeding in the dermis. |
| What is a generally accepted guideline for a timeframe to define a chronic wound? | 3 months |
| How large of a perimeter should be observed when assessing periwound skin? | At least 4 cm. |
| What is a sinus tract? | It is a channel or a path extending from the surface of an organ to an underlying area or abscess cavity that has a closed end. |
| What are the characteristics of a sinus tract? | Closed end, lined with granulation or epithelial tissue, often expels exudate. |
| What is it called when drainage permeates through a dressing? | Strikethrough. |
| What typically causes a sinus tract? | Infection or a foreign body, like a blocked hair follicle causing an ingrown hair. |
| What is undermining? | Tissue destruction of underlying intact skin along the wound margins. (Makes wound larger at the base than the skin surface.) |
| What do each of the anatomical locations indicate for possible etiology of the wound? | Bony prominence = Pressure Folds of skin = Friction, moisture Toes = Footwear friction, arterial insufficiency Bottom of foot = diabetes, pressure Shin or calf = trauma, circulation issues |
| What might the shape of a wound indicate about the possible etiology of it? | Round/ elliptical = pressure Jagged edges = Shear or friction Irregular shape = Vascular Linear = Trauma or friction |
| What are the depths of partial thickness v. full thickness wounds? | Partial = <0.2 cm (through epidermis and dermis only- never yellow) , Full = >0.2 cm (extends into SubQ or further) |
| What is the minimum for megapixels used for a camera used for documenting wounds? | 3 megapixels. |
| What is stable eschar? | Intact, firmly adhered, no inflammation, not fluctuant or crepitant, not boggy or soft. |
| What is unstable eschar? | May be boggy with drainage, edema, inflammation or pain. |
| What happens to moisturized eschar? | It turns to slough. |
| What is slough? | Hydrated necrotic tissue. |
| What do the different colors of slough indicate? | White = little bacterial colonization, yellow or green = presence of bacterial colonization, brown = presence of hemoglobin. |
| What happens to slough as it ages? | It becomes thicker. |
| Is granulation tissue present in partial-thickness wounds? | No. Full thickness only. |
| What is the appearance of granulation tissue? | Beefy red, puffy, bumpy, moist, shiny, cobblestone secondary to capillary buds. |
| Is bridging epithelium a desirable occurrence? | No. |
| What do the colors of wound bed tissue mean? | Red = Healthy and perfused Pale pink = Poor perfusion from anemia Purple = Engorged from sealling or high levels of bacteria Black, brown, yellow, tan = Non viable, necrotic Green = Infection/ non-viable White = Poor blood flow or maceration |
| What are the significance of colors of exudate? | Clear/ amber = Infection or fluid from a urinary or lymphatic fistula, green = bacterial infection, pink/red = presence of RBCs |
| What is the significance of high or low viscosity in wound exudate? | High = High protein content Low = Low protein content |
| What are the definitions for the amounts of exudate? | Dry = no exudate, Scant = Moist but with no measurable drainage, Small/minimal = Wound is wet but covers less than 25% of bandage, Moderate = 25-75% of bandage covered, large/copious = greater than 75% of bandage covered. |
| What does anaerobic bacteria smell like in a wound? | Acrid, rotten, or putrid. |
| What does pseudomonas smell like? | Fruity or sweet. |
| What type of bacteria is more likely to cause wound odor? | Anaerobic. |
| What is an affluent wound? | A non-infected wound. |
| What is an epibole? | A rolled under or curled wound edge, delays healing. |
| What is an induration? | Hard tissue that is a red flag for infection, undermining, or tunneling. |
| What does hyper-keratonic mean? | Calloused. Common in diabetic foot ulcers. |
| How can you tell if erythema is related to infection? | It will have diffuse and indistinct edges, may be intense in color and well-demarcated, may appear as streaking. |
| What is fluctuance? | Moveable, palpable, fluid-filled, wavelike motion. |
| What is crepitus? | Build up of air or gas in tissues from fermentation of carboydrates into Co2 and hydrogen. - Snap, crackle, pop. |
| What is nociceptive (acute) pain? | Localized, constant, time-limited that originates from tissue damage. |
| What is neuropathic pain? | From malfunctioning nerve fibers, "burning" or "electric shock" |
| What is incidental pain? | Noncyclical. Caused by debridement or trauma. |
| What is episodic pain? | Cyclical. Can be caused by dressing changes, open air, medication burning, or cleansing. |
| What is PQRST for pain assessment? | Provokes, Quality, Radiates, Severity, Time |
| What pain assessments are used for pediatric age groups? | 2 mo - 7 years, FLACC. Infants up to 6 months, CRIES, Over 7 years, VAS or FACES |
| What are the three key components of wound documentation in the PUSH tool? | SET = Size, Exudate, Tissue Type. |
| What is the 5th vital sign? | Pain |
| What areas have no SubQ tissue? | Ear, bridge of nose, malleolus |
| What stages must areas with no SubQ tissue be assigned if they are open to pressure? | I, II, or IV |
| Is smaller or higher better on the PUSH tool? | Smaller is better. |
| What does the PUSH tool monitor? | Tissue healing over time. |
| What are the four stages of healing? | Hemostasis = activation of platelets and secretion of growth factors, Inflammatory = Removal of debris, Proliferation = fibroblasts create collagen to fill and cover, Maturation = remodeling and tensile strength. |
| What are the two types of debridement? | Selective (removes only non-viable, dead tissue), and non-selective (removes viable and non-viable tissue) |
| What is healing by primary intention? | Wound edges brought together and sutured or stapled. |
| What is healing by secondary intention? | Wound is left open to granulate and contract naturally. |
| What is healing by tertiary intention? | Surgical closure after a time delay to allow for decrease of edema/ infection. |
| What is the benefit of primary healing? | Minimal risk of infection, low tissue loss, low scarring |
| What are cons of secondary intention healing? | More tissue loss, higher risk of infection, decreased tensile strength, longer healing times. |
| What is the timeframe for epidermal resurfacing? | It peaks at 48-72 hours. |
| What can slow epidermal resurfacing? | Presence of bacteria or dry scabbed tissue. |
| What are the advantages of moist wound healing? | Prevents dehydration, promotes angiogenesis, allows re-epithelialization, and minimizes pain. |
| How drastic does a temperature drop need to be to negatively impact the biological process of healing? | 2 degrees |
| What are the ideal low and high body temps for wound healing? | Above 91.4 degrees to below 107.6 degrees |
| How does cooler tissue increase the risk for wound infection? | Vasoconstriction increases hemoglobin's need for oxygen and results in decreased O2 availability for neutrophils. |
| What is the most inappropriate dressing for keeping a wound warm? What is the most appropriate? | Inappropriate = gauze. Appropriate = Foam. |
| What is hypoxia? | Inadequate amount of oxygen for supporting biological wound healing. |
| What cells require oxygen for healing? | Neutrophils and macrophages (kill bacteria), fibroblasts (create collagen), epithelial (proliferate, contract) |
| What factors can negatively impact chronic wound healing? | Prolonged or excessive inflammation, no initial bleeding, cellular senescence (old/unresponsive/unable to divide), deficiency of growth factor receptor sites, high levels of proteases, persistent infections, or formation of microbial biofilms. |
| What are the most common age-related changes to the EPIdermis? | Flattening of BMZ. Decrease in Langerhans and melanocytes (increasing risk for skin cancer), decreased rate of epidermal turnover. |
| What are the most common age-related changes to the dermis? | Fewer fibroblasts, macrophages, and mast cells, reduced vascularity, loss of collagen, decreased elastin. |
| What are the benefits of using medicinal maggots for biological wound debridement? | It is rapid and selective |
| What are the four types of debridement? | BEAM = Biological/ biosurgical, Enzymatic/chemical, Autolytic, Mechanical |
| Medicinal maggots act in three ways. Name them. | Debridement of wound, disinfection of wound, and stimulation of wound healing. |
| What innoculation should be checked if a wound is infected with street maggots? | Tetanus |
| How many maggots are indicated for wound care? | 5-10 per cm of wound surface. |
| How long are maggots generally left in place? | 48 hours |
| What is myiasis? | The condition of accidental maggot infestation (street maggots) |
| How can "street maggots" be removed from a wound? | Moisten with NaCl, Hydrogen peroxide, or Dakins |
| If "street maggots" don't come off with a rinse, what can be done? | Soak the wound for 20 minutes in 1 part 3% hydrogen peroxide and 4-5 parts room temp sterile saline or sterile water. |
| What is the optimal pH range for debridement with Santyl? | 6-8 |
| Can a partial thickness wound develop a scar? | No. |
| What impact can high levels of proteolytic enzymes in exudate have on wound healing? | It can break down healthy tissue and inhibit fibroblast production. |
| How long can it take a wound to return to body temperature once it has been uncovered? | Up to 4 hours. |
| What medication class can be a strong culprit for wound dehiscience? | Corticosteroids- they can suppress collagen formation. |
| What are two signs of decreased phagocytic activity? | Decreased exudate and persistent slough. |
| What type of debridement is not reliable for a wound with a large surface area? | Autolytic. |
| What are the contraindications for autolytic debridement? | Infected wounds, immunocompromise, and and large amounts of necrosis., exposed bone or tendon or friable skin |
| For which type of patient is autolytic debridement an ideal choice? | Terminally ill. |
| What is the slowest form of debridement? | Autolytic. |
| When should you expect to start seeing outcomes from autolytic debridement? | 72-96 hours. |
| When is autolytic debridement indicated? | In a non-infected wound with minimum/moderate necrotic tissue wherein minimum dressing changes will be required. |
| What type of debridement is safe for patients on blood thinners? | Autolytic. |
| What type of dressings are used for autolytic debridement? | Hydrogel if wound is dry, transparent dressing. If wound is moist, hydrocolliod. If wound is wet, alginate/hydrofiber/foam. |
| What is mechanical debridement? | Use of external force to remove necrotic tissue. |
| What are contraindications for mechanical debridement? | Epithelializing wounds, granulating wounds, poor perfusion, intact eschar, inadequate pain control |
| What are the methods of mechanical debridement? | Scrubbing, monofilament fiber dressing (ex: Debrisoft), Irrigation, low-frequency ultrasound, wet-to-dry (now considered outdated), sharp debridement. |
| How is the force of irrigation measured? | By PSI- Pounds per square inch. |
| What is the safe PSI for mechanical wound debridement? | 4-15 PSI. |
| What are the levels of PSI? | Low = <8 High = 8-15. |
| How can one achieve 8 PSI for mechanical wound debridement? | A 19g needle with a 35 ml syringe. |
| Why are wet-to-dry dressings contraindicated? | They are non-selective, doesn't maintain normal tissue temperature, increases infection rates, and larger amounts of bacteria are dispersed into the air by removal of dry gauze. |
| What is the fastest method of debridement? | Sharp debridement. |
| What are the indications for sharp debridement? | Infected wounds, advancing cellulitis, wound-related sepsis, extensive necrotic tissue, inability to determine degree of undermining and tunneling, infected bone or hardware |
| What are the contraindications for sharp debridement? | Bleeding disorders, ischemic wound, severe arterial insufficiency, dry gangrene, malignant wounds, unidentifiable structures, stable/intact heel eschar. |
| What are the two types of sharp debridement? | Sharp surgical (done by surgeon, cutting into viable tissue), and sharp conservative (bedside by trained practitioner or physician if in scope of practice)- removes only devitalized tissue and may require several sessions. |
| Is surgical debridement indicated for diabetic foot ulcers? | Yes! It is recommended over other forms of debridement. |
| What indicates a biofilm may have formed over a wound? | Failure of antibiotic therapy, recalcitrance to antimicrobial therapy, increased exudate or moisture, poor granulation or friable hypergranulation, low level of erythema. |
| Are all wounds contaminated? | Yep. |
| Is there such a thing as a sterile wound? | No. |
| How can biofilm be removed? | Aggressive sharp debridement with regular debridement and vigorous physical cleansing. |
| What is colonization? | Bacteria reproducing. It does not cause symptoms because healthy tissue is not invaded. |
| What is the golden standard for providing the most accurate data regarding the type and quantity of pathogenic bacteria? | A punch biopsy. |
| What would be some covert symptoms of local infection? | Hypergranulation, bleeding/friable granulation, epithelial bridging or pocketing in granulation, wound breakdown and enlargement, new or increasing pain, and increased wound odor. |
| What are some overt (classic) symptoms of local infection? | Erythema, warmth, swelling, purulent drainage, delayed wound healing, new or increasing pain, increased odor. |
| What are some signs of spreading infection? | Extending induration with or without erythema, lymphangitis, crepitus, wound breakdown or dehiscience with or without satellite lesions, malaise, loss of appetite, inflammation of lymph glands. |
| **Review the picture guide for types of skin lesions** | **Review the picture guide for skin lesion types** |
| What are the possible causes of highly viscous exudate? | Infection, necrotic material, enteric fistula, or residue from dressings. |
| What are the possible causes of low viscosity exudate? | Venous or congestive cardiac disease, malnutrition, or urinary/lymphatic/joint space fistulas. |
| What must be done before determining if a wound has an odor? | Cleanse the wound. |
| What are the two main mechanisms of healing? | Regeneration and scar formation. |
| When are oral or IV antibiotics indicated? | When infection spreads beyond the margin of the ulcer. |
| What cells respond in the inflammatory stage of healing? | Neuts and Macs (Neutrophils and Macrophages) |
| What are the tensile strength estimates during the phases of the maturation stage of healing? | At 21 days, the skin is only at 20% strength. It will gradually reach 80% strength. |
| What can the overproduction of inflammatory cytokines lead to? | Inability to heal. |
| What do MMPs (Matrix Metalloproteinases) do? | Debride damaged tissue, angiogenesis, re-epithelialization, wound contraction, and scar remodeling. |
| Should a barrier film be used under an extended-wear ostomy pouch? | No- it is designed to come in direct contact with the stratum corneum. |
| What types of medications can delay healing? | Corticosteroids, NSAIDS, Vasoconstrictors, Anti-platelets, Antineoplastics, Anti-rejections, and Anticoagulants. |
| How does immunosuppression result in delayed healing? | It decreases phagocytic activity and increases risk for infection. |
| What issues are often noted with diabetes for wound healing? | Prolonged inflammatory phase, reduced collagen production, impaired epithelial migration, altered cytokine and growth factor, and altered blood glucose. |
| Is adipose tissue well perfused? | No. |
| What impact does smoking have on wound healing? | It impairs white blood cell migration, resulting in lower monocytes and macrophages which leaders to increased risk for infection and slower healing. |
| What percentage of healing over 2 weeks is predictive of healing for a newly treated venous leg ulcer? | >30% reduction in ulcer surface area. |
| If a diabetic foot ulcer doesn't heal 50% in the first 4 weeks of treatment, what trajectory is likely? | There is a 9% chance it will heal in the next 3 months. |
| What are the four major components of wound bed preparation? | TIME = Tissue management, Inflammation and infection control, Moisture balance, Epithelial edge advancement. (May add RS for Repair/regeneration and Social/patient related factors.) |
| What are three possible goals for healing that must be known before a plan of care is formulated? | Healing, maintenance, or palliation. |
| What are some contraindications to sterile maggot therapy for a wound? | Allergies to brewers yeast, fly larvae, or soy proteins; wounds with vital organs exposed blood vessels, wounds likely to communicate with the CNS, Limb or life-threatening acute wounds, necrotic bone or tendon, pyoderma gangrenosum. |
| What are the pros of using Santyl? | It is fast-acting, highly selective. |
| What thickness is used for Santyl application? | 2 mm |
| What can be done to necrosis to allow Santyl to penetrate better? | Crosshatching -or- sharp debridement for heavily necrotic wounds. |
| What is bioburden? | The presence of microorganisms (bacteria) on or in a wound. |
| What is a normal BMI? | 18.5-24.9 |
| What are the parameters to identify "significant weight loss"? | 5% in 30 days, or 10% in 180 days. |
| What is the process that results in unintended weight loss? | Catabolism (breakdown of protein stores for metabolism or energy.) |
| When there is a loss of LBM (Lean body mass) of <10%, wound healing does what? | It takes priority. |
| What happens at 20% LBM loss? | There is balance for wound healing and LBM restoration. |
| What happens at >30% LBM loss? | The priority for protein intake is directed to restoring the LBM. |
| What is <3.5 g/dL of Albumin indicative of? | Malnutrition |
| What is the half life of albumin? | 20-22 days |
| What is <19.5 mg/dL of serum prealbumin indicative of? | Malnutrition |
| 80-130 is the recommended level for what? | Preprandial glucose. |
| What is the normal range of an A1C ? | 4.5-5.7. |
| Recommended A1C for diabetics are what? | 7% for non-pregnant adult, 8% may be acceptable. |
| What is the caloric daily intake recommended for healing? | Appox 30-35 kcal/kg/day, or 40 if the patient is underweight. |
| How much protein can a patient lose due to wound exudate? | Up to 100g a day. |
| What balance does protein help preserve? | A positive nitrogen balance. |
| What is the range of protein recommended for healing? | 1.2-1.5 grams per kilogram per day. |
| What are the fat-soluble vitamins? | ADEK- A is essential for collagen formation, D is used for calcium metabolism and building bone, E is for fat metabolism and collagen, and K is for coagulation |
| What is the recommended amount of fluid for patients with wounds? | 1 ml per cKal consumed per day. |
| What is phlegmon? | Spreading diffuse inflammatory process with purulent exudate or pus in a neuropathic or diabetic ulcer. Indicates infection. |
| How can symptoms of infection be masked in diabetic patients? | They may have an inflammatory response that is not typical. |
| What should trigger the consideration of possible osteomyelitis? | Deep or extensive wounds (esp over bony prominences), ulcer not healing after 6 weeks of care, bone visible or easily palpable. swollen foot in pt with hx of foot ulcer, unexplained high WBC, xray bone destruction, wound heals/reopens repeatedly. |
| The goal for wound healing from nutrition standpoint is what? | To provide adequate calories and protein. |
| When should a nutritional screening be conducted? | Admission (within 24 hours), significant status change, or stalled healing. |
| What amino acids are needed for wound healing? | Arginine and glutamine |
| What is an "off-label" use? | Use of non-FDA approved medications or a medication or product for something beyond its essentially intended use. |
| What is the first rule of healing? | Determine the cause of the wound and implement interventions to remove or control that cause. |
| Do you care for a clean wound or a dirty wound first on a single patient? | Clean first, then dirty. |
| What should "surgical dressings" be associated with? | Primary and secondary dressings. |
| What dressing touches the wound? | Primary. |
| What does a secondary dressing do? | Secures the primary. |
| How often do you clean a wound? | On each dressing change. |
| What can you clean wounds with? | Normal Saline or Potable (drinkable) water |
| When should you consider using a surfactant or antimicrobial cleanser? | For wounds with debris, confirmed or suspected infection, or suspected increased levels of colonization. |
| When must a bottle of normal saline be discarded? | Within 24 hours of opening. |
| What do surfactant cleansers contain? | Both hydrophilic and hydrophobic elements that loosen particles and suspend them in the water. |
| Are skin cleansers the same as wound cleansers? | No- skin cleansers are stronger and often not appropriate for wound care. |
| What is another name for an alginate (or "calcium alginate") dressing? | "Sucker uppers" |
| What do alginate dressings do? | Transform into a gel once they come into contact with an exudate and maintain a moist healing environment, thus facilitating autolytic debridement. |
| What kind of wound is alginate dressings used for? | Moderate to heavily exuding, to fill dead space. OK for bleeding or infected wounds. |
| What kind of wound is an alginate not used for? | Third degree burns, eschar, or minimally draining wounds. |
| How often is an alginate changed? | 1-3 days based on exudate or else when strikethrough is seen. |
| What should you not use an alginate dressing in combination with? | Hydrogel. |
| When is the only acceptable time to use a collagen dressing? | When there is good blood flow (perfusion). |
| What does a collagen dressing do? | It encourages granulation and organization of collagen fibers. |
| What kind of wounds can collagen dressing be used for? | Chronic, non- healing, granulated, tunneling, skin grafts, minimal to heavy exudate. |
| When are collagen dressings contraindicated? | Sensitivity to bovine, porcine, or avian products, third degree burns, or dry eschar. |
| What can a composite dressing be compared to? | A Band-Aid (example: Telfa) |
| What is a ridiculous phrase to remember the layers of the epidermis? | Corn for the Lucky Granny Spins her to Germany. (Corneum, Lucidum, Granulosum, Spinosum, Germanativum.) |
| Are a majority of the cells on the epidermis well-perfused? | No. The epidermis is avscular and is mostly composed of dead cells. |
| What kind of cells produce keratin? | Keratinocytes. |
| Who is the coolest student in the 2023 WCC course at the KHA? | Just kidding. You guys are all awesome. Thanks for walking through this journey with me! :) |
| What is the dermis made up of? | Collagen and elastin. (Bonus tip: Ditto on granulation!) |
| What does a healthy level of proteolytic enzymes do? | They dwell inside WBCs and get rid of waste. |
| How many directions can tunneling extend into? | One. |
| What kind of force results in tunnelling and undermining? | Shearing. |
| What two things must be documented for tunneling? | Depth and direction. |
| Does linear measurement alone include periwound assessments? | No. Linear measurement is just the wound from edge to edge. Document the periwound in addition to this measurement. |
| At what part of the wound should an assessment begin? | Its center. |
| What color is epithelial tissue? | Deep to pearly pink |
| What is the "configuration" of a wound? | Its shape. |
| If a wound is described as "fibrotic", "calloused", or "hyper-keratonic", what does it look like? | It has a dry, tough, scaly appearance. |
| By what means does excoriation (linear erosion) occur? | Mechanical. |
| What does a Stage I pressure ulcer look like? | Alive, red (non-blanchable), may be painful, may be soft, may be warmer or cooler than the surrounding skin. |
| What is a positive aspect of red skin? | Red is not dead! It may be still be viable. |
| What does a stage II pressure ulcer look like? | No granulation, no slough, no eschar, partial thickness (epidermis and dermis only), pink, painful. |
| What stage is a serum-filled blister when it is from pressure? | Stage II |
| What are the three "P's" of a stage II pressure ulcer? | Pink, painful, partial [thickness] |
| What does a stage III pressure ulcer look like? | Full thickness, may have slough/eschar, may have granulation, will NOT have muscle, bone, or tendon exposed. |
| What does a stage IV pressure ulcer look like? | Extends to the fascia or lower, and exposes bone, muscle, or tendon. |
| What does a DTI (deep tissue injury) look like? | It is intact, but with mushy or boggy texture, purple or maroon. |
| What is a blood-filled blister classified as if it is a pressure wound? | DTI (Deep Tissue Injury.) |
| What is the difference between a Stage I pressure ulcer and a DTI? | The tissue on a DTI will be boggy or mushy. |
| How do partial-thickness wounds heal? | Through re-epithelialization. |
| During which phase of healing does autolytic debridement occur? | Inflammatory. |
| How long does the proliferative phase of healing generally last? | 4-24 days. |
| How long does the maturation phase of healing take? | Up to one year. |
| How long does it take cell migration to bind together after closure of a wound by primary intention? | 2-3 days |
| What do we know to be true about a dry cell? | It is a dead cell. |
| Which types of debridement are selective? | Bioligical, enzymatic, autolytic, and conservative sharps. |
| Which types of debridement are non-selective? | Mechanical, surgical sharps. |
| What is enzymatic debridement? | The application of collagenase (ex: Santyl.) |
| What indicates critical colonization? | One or two symptoms of increased bioburden in the wound or within the 4 cm periwound diameter. |
| How many symptoms are considered to indicate the presence of an infection? | Three or more. |
| What is the Levine method? | Manual expression of exudate ("wound juice"). After cleaning the wound with non-antiseptic solution (saline), rotate a swab over a 1 cm area with pressure sufficient to get exudate. Note: Do NOT swab over eschar or slough. |
| Should a wound culture be done on eschar or slough? | No. |
| What are the three lab tests that can indicate osteomyelitis? | CBC, ESR, CRP. |
| What is the second most common pathogen? | Pseudomonas. |
| Where is psuedomonas often found? | Around hydro- or pulmonary equipment. |
| What is the acceptable range for Group B Hemolytic Streptococcus? | Zero. The only acceptable number is none. |
| What type of pathogen infection requires immediate treatment with IV Penicillin or Vancomycin? | Group B Hemolytic Streptococcus. |
| What are the two key objectives for an infected wound? | Reduce the existing bioburden and achieve a host-manageable bioburden for future state. |
| Why should topical antiseptics only be used for a limited time? | They can delay healing by killing healthy cells when used for too long. |
| What are some examples of topical antiseptics? | Dakins, Betadine, Acetic Acid (vinegar) 0.25-0.5%, Hydrogen peroxide 3%. |
| What type of infection is Dakins indicated for? | Gram positive, like strep or staph. |
| What type of infection is Acetic acid indicated for? | Gram positive OR gram negative, especially pseudomonas aeroginosa. |
| What common antiseptic can be cytotoxic? | Hydrogen peroxide. |
| What are synthetic, broad-spectrum antibiotics? | Quinolones/ fluoroquinolones. (Examples: Cipro, Levaquin.) |
| What is an important indication when using quinolones or fluoroquinolones? | A 50% reduction in coumadin dosing during use and for one week following use. |
| What kind of treatment can decrease the contraction of fibroblasts? | Silver sulfadiazine. |
| What must happen if an epibole forms? | Re-injury of the margins of the wound to trigger the continuation of healing. |
| What are three considerations when using silver nitrate for cauterization? | Protect the healthy tissue (vaseline), moisten the tip of the swab with water ONLY, and clean the treated area with damp saline gauze after the treatment is done. |
| What are the two situations in which we want to make a healing wound bleed? | If an epibole forms, or if the tissue is smooth/flat/shiny. |
| How can bleeding be induced? | With sharps, silver nitrate, or rubbing. |
| What is the timeframe for the peak effectiveness of pain meds? | Parenteral = 15-30 minutes, Oral = 60 minutes. |
| What is decreased in the malnourished patient? | Collagen production. |
| What is PEM? | Protein energy malnutrition. It results from involuntary weight loss, wherein LBM (lean body mass) is depleted. |
| What three lab values measure visceral protein? | Albumin, prealbumin, and transferrin. |
| What deficiency wouod contraindicate the use of transferrin for diagnostic definition of a protein deficiency? | Patients with iron deficiency. |
| What is an "at risk" level of transferrin? | <200mg/dL. |
| What is the kgs to lbs conversion formula? | 1 kg = 2.2 lbs. |
| What is arginine? | An amino acid used as a building block for protein. |
| What is glutamine? | A amino acid necessary for protein anabolism. |
| What are vitamins A and C crucial for? | Collagen formation and fibroblast function. |
| What are the fat-soluble vitamins? | A, D, E, K. |
| What vitamin protects vitamins A and C? | Vitamin E. |
| What is the treatment for pernicious anemia and why? | Injected Vitamin B12, because patients lack the protein intrinsic factor in supply sufficient for absorption of oral B12. |
| What is the nutritional goal for wound healing? | Provision of adequate calories and protein. |
| How long of a stall in healing is needed for treatment re-evaluation to be indicated? | 2 weeks |
| What type of dressing touches the actual wound? | Primary. |
| What page in the handbook has the reference for lower extremity wounds? | Pg 334! |
| What disease process for lower extremity wounds is associated with Diabetes? | Cellulitis. |
| What disease process affecting lower extremity wounds is considered neuropathic? | Osteomyelitis |
| What is a high-level statement regarding aterial disease wounds? | Things die. :( |
| What is considered the golden standard for BEDSIDE diagnostic of significant arterial disease (aka, screening). | The ABI (Ankle-Brachial Index) |
| What two pulses should be assessed to determine perfusion of lower extremities? | Dorsalis pedis (pedal) and posterior tibial (inner ankle, below malleolus.) |
| How do you check for rubor dependency to assess perfusion of lower extremities? | Raise leg to 60 degree angle for 15-60 seconds, and observe how long it takes for pallor to appear on the soles of the feet. Within 25 seconds = Severe occlusive , 25-40 seconds = Moderate occlusive , and 40-60 seconds = Mild occlusive |
| What does ABI compare? | Systolic blood pressure of the ankle to that of the arm. |
| How often should the ABI be done for persons with non-healing lower extremity wounds or lower extremity | Every 3 months. |
| Why do you perform an ABI? | To rule out significant arterial disease. |
| What is contraindicated if an ABI comes back with negative findings? | Venous compression. |
| What equipment is needed for an ABI? | BP cuff and a Doppler. |
| What indicates the need for an ABI? (4 things) | Foot pulses not clearly palpable, any patient with a lower ext. ulcer, an ulcer is not healing, and any time a compression order is in place. |
| What is another word for the big toe? | "Hallux" |
| Why might an ABI not be accurate for a diabetic? | BP cuffs can't compress calcification of ateries |
| ABI Values | Normal ABI = 1-1.4, Non-compressible = >1.4, Borderline = 0.91-0.99, Abnormal= less than or equal to 0.90, Clinical ischemia = <0.5. |
| What is the alternate exam for the ABI when lower extremity PAD is suspected but ABI can't compress arteries accurately? | The TBPI - Toe Brachial Pressure Index. |
| What is the gold standard for DIAGNOSIS (formal, not bedside) of arterial disease? | The Angiogram. |
| TBPI Values | Normal = >0.7, Abnormal <0.64 |
| What are the three theories of venous ulcerations? | Fibrin cuff, WBC trap, and trap hypothesis. |
| What is an abnormal finding for Skin Perfusion Pressure? | <30 mmhg = severe PAD |
| Which profession performs Lanarkshire? | Physical Therapy ONLY. |
| At what point from the ground is calf edema measured? | 5 cm above the medial malleolus. |
| What functional deficiency can result in venous insufficiency? | Failing valves |
| Where are venous ulcers typically found? | Medial lower leg, ankle, above medial ankle. NOT typically on foot or above knee. |
| What is an average healing time for a venous leg ulcer? | 24 months. |
| What do wound margins often look like on venous leg ulcers? | Irregular |
| What are often causes of venous insufficiency? | Calf muscle weakness or degradation, valve dysfunction, venous stasis |
| What do venous leg ulcers look like? | Superficial, ruddy/granular tissue, possible yellow slough, moderate to heavy exudate, may have hemosiderin staining, may have woody edema. |
| What do legs look like when venous insufficiency is present? | Scaly, weepy, warm, hairy, may have woody edema. Periwound skin may become macerated. |
| How severe is pain with venous ulcers? | Minimal to moderate |
| Who may be at risk for venous ulcers? | Obese, pregnant, advanced age, thrombophilia, CHF, incompetent valves, sedentary lifestyle, family history. |
| What is the treatment for venous insufficiency? | Sustained graduated compression. May also employ cool compression or topical steroids. |
| Will edema be present with venous insufficiency? | Yes. It's a given. |
| What is the quality of pain with venous wounds? | Dull, aching, itchy, sharp, throbbing. Worsens with dependency. Relieves with elevation. May feel like heaviness. |
| What is lipodermatosclerosis? | Woody induration where fibrous tissue replaces the fatty layer, edema remains above the area. May see "inverted champagne bottle" or "bowling pin." |
| What is atrophie blanche? | Smooth, ivory-white plaque with irregular hyperpigmented border and surrounding telangiectasia (red dots of dilated capillary loops). Associated with venous insufficiency. |
| What is an associated finding with venous wounds that requires IV or oral antibiotic treatment? | Cellulitis. |
| What is a benefit of composite dressings? | They allow for the exchange of moisture vapor. |
| What type of wound is a composite dressing indicated for? | Partial or full thickness, minimum to heavy exudate, granulation or necrotic tissue. |
| What are contact layer dressings made with? | Silicone. |
| What are good treatments for venous dermatitis? | Topical emollients, or Domeboro compresses for weeping or itching. |
| When are contact layer dressings indicated? | For fragile tissue or with a wound vac. |
| When are contact layer dressings contraindicated? | Shallow wounds, dehydrated wounds, eschar, thick exudate. |
| What is the CEAP system? | Classification for wounds: Clinical, Etiology, Anatomy, and Pathophysiology |
| What is compression therapy used to treat? | Lower extremity venous ulcers or venous insufficiencies. |
| What is a benefit of foam dressings in terms of fluid? | They are semi-permeable = impermeable to bacteria band waterproof but allowing escape of water vapor. |
| What is a MAJOR contraindication for foam dressings? | Infected wounds. Also contraindicted for eschar, third degree burns, or sinus tracts. |
| When are hydrocolloid dressings indicated? | Scant to moderate drainage, non-infected wounds. Necrotic OK. Granulating OK. Can be used to protect newly healed skin. |
| Is a hydrocolliod dressing primary or secondary? | Primary only. |
| Why is a hydrocolloid dressing not good for infected wounds? | It is occlusive; nothing in/ nothing out. |
| What three types of dressings should NOT be used on infected wounds? | Hydrocolliod, film, or foam. |
| What dressing should be warmed before application? | Hydrocolloid. |
| What are contraindications with hydrocolloid dressings? | Infection, heavy exudate, deep tunnels, tracts, or undermines, fragile periwound skin, and be VERY cautious with diabetic feet. |
| What is considered a moisture-retentive dressing? | A hydrocolloid. |
| What type of dressing is considered semi-permeable (allowing oxygen and moist vapor out but no bacteria or water in)? | Transparent film. |
| What can a lateral rotation bed contribute to? | Shearing. |
| What is a dermatome? | A wound pattern along a nerve. |
| What is the best treatment for a sickle cell ulcer on a lower extremity? | Unna boots. |
| What is a handy phrase to remember when TED hose are indicated? | TEDS are for beds. (Anti-embolism stockings are indicated for bed-bound patients.) |
| What is the classification scale for diabetic ulcers? | Wagner. |
| How prevalent is PAD (peripheral arterial disease) in persons with diabetes? | They are 4x more likely to develop it. |
| What is the #1 risk factor for ulceration that increases risk for amputation? | Peripheral neuropathy. |
| What test can check for sensation in diabetic feet? | Semmes Weinstein Monofilament. |
| What is the LaPlace Law (or equation) for compression? | More layers plus more tension on a bandage results in increased pressure. A larger leg circumference plus a wider bandage results in decreased pressure. |
| What is a Duke boot? | A hydrocolloid dressing with an Unna boot and Coban over it. |
| What are the goals for venous patients? | Compression for life, with knowledge of the disease process and chronicity. |
| What does dermatitis look like? | Cellulitis, but indicates a chronic inflammatory condition. |
| List the ABI guidelines for tension | Low level = 23-30 mmhg High level = 30-42 with no evidence of acute CHF. |
| Contraindications for compression | Decompensated CHF, ABI less than 0.5, Ankle pressure less than 70 mmHg, Toe pressure less than 50 mmHg |
| How long can compression remain in place? | Up to 7 days. |
| When is lower compression indicated? | Intolerance due to discomfort. |
| Does an Unna boot provide compression? | No (unless it is converted into a Duke boot.) |
| What type of patient is an Unna boot recommended for? | Ambulatory. "These boots are made for walking." |
| How much overlap is indicated for an Unna boot? | 50% |
| What is a short stretch single-layer wrap? | Inelastic, most appropriate for ambulatory patients. Useful for thin ankles, edematous feet, and mixed arterial and venous disease. |
| What are the benefits of short stretch single-layer wraps? | Washable, can be removed for bathing |
| What is a short stretch reusable inelastic device? | Secured with velcro, Adjustable to 20-50 mmHg, straps prevent slippage. |
| What is a downside of long stretch reusable wraps? | If the leg is unevenly shaped, it can slip. |
| ACE wraps are inappropriate for what? | Venous ulcerations or venous hypertension. |
| What is a benefit of long stretch compression with multi-layer wraps? | Provides benefit when active AND when at rest. |
| What is the key feature of long stretch compression with multi-layer wraps? | Great for exudate absorption. |
| List the tips for applying compression wraps. | Start at base of toes, include heel, DO NOT wrap directly on infected wound (tx first), then wrap should extend to 1" below the knee. Assess patient 20 minutes after application. |
| What should you do if you have leftover dressing at the top of the knee? | Cut it off. |
| Are TED hose indicated for long-term compression? | No. They only provide 8-18 mmHg, used for immobile patients, and prevents DVTs. |
| What is the pressure suggested for venous ulcer management? | 30 mmHg and above. |
| What are ancillary interventions for venous ulcer healing? | Elevate feet to level of heart 30 minutes 3-4 times daily. Refer to PT for calf pump activation. Consider medications to increase blood flow (example: Trental.) |
| What does the acronym CORE stand for? | Compression, Optimize local wound environment, Review contributing factors, and Establish a maintenance plan. |
| What are the most common locations for arterial ulcers? | Between toes, tips of toes, over phalangeal heads, around the lateral ankle, or over areas of friction or rubbing. |
| What are associated findings with arterial ulcers? | Shiny skin, hairless, thick toenails, pallor on elevation, dependent rubor, cyanosis, cool in touch, diminished or absent pulses. |
| When can pain begin with alterial ulcers? | Pain begins with intermittent claudication. |
| What are common characteristics of an arterial ulcer? | Has a "punched out" appearance, pale, deep, minimal exudate, even wound margins, blanched peri-wound tissue, possible cellulitis or gangrene/ necrosis. |
| What is LEAD? | Lower extremity arterial disease. |
| What are the most common treatments for critical limb ischemia? | Revascularization or amputation. |
| What are two things to remember about dry gangrene? | It is VERY malodorous, and is a medical emergency. |
| What is the golden standard for diagnosis (formal) of LEAD? | Angiogram. |
| What kind of pain may an arterial patient experience? | Nocturnal/ positional pain with elevation. |
| What is the most common procedure to establish revascularization for LEAD? | Femoral-popliteal bypass. |
| What does an ABI of 0.6-0.8 indicate in terms of etiology for vascular issues? | Mixed etiology. |
| What is atypical claudication? | Pain that is aching or cramping that results from activity and is relieved by rest. |
| What does the line of demarcation mean? | The clear place where necrotic tissue stops and viable tissue begins. |
| What is wet gangrene? | Sudden interruption of blood supply; burns/ freezing. No line of demarcation. |
| What is gas gangrene? | Occurs when wet gangrene becomes infected. |
| What is the priority treatment with dry gangrene? | Keeping it dry, no debridement. May allow for auto-amputation. May treat with povodine-iodine or alcohol. |
| What is the priority treatment with wet gangrene? | Preventing the spread of infection. |
| What are the signs of mixed venous and arterial disease? | Edema, hyperpigmentation, venous ulcers, impaired wound healing, full-thickness tissue depth of ulcers. |
| When is a vascular specialist indicated? | ABI <0.5 |
| ABI Cheatsheet on flip side of this card. : ) | 1 = Normal 0.9 = Venous 0.6-0.8 = Mixed 0.5 = Arterial Less than 0.5 = Refer to a vascular specialist |
| What are common deformities in diabetic feet? | Hammer toes, Charcot, Thick toenails |
| What is a finding on the foot of a diabetic that requires immediate treatment? | A callous. |
| What symptoms indicate acute charcot? | Painless, swollen, slightly red, warm, crackling joints. |
| What is the treatment for charcot? | Total contact casting. |
| What are the common skin/bone complications that derive from diabetes? | Osteomyelitis, cellulitis. |
| Where are diabetic ulcers typically located? | Bottom of feet, metatarsal heads, heels, toes. |
| What shape are diabetic ulcers typically? | Rounded or oblong. |
| What is the number one goal to facilitate the treatment of diabetic ulcers? | Glucose control. |
| What is the gold standard for weight-bearing mitigation for diabetic ulcers? | Total contact casting (offloading), aka TCC. |
| Risk factors for diabetic ulcers | A1C >7, DM for greater than 10 years, previous ulcers, PVD, nail pathology, smoking, obesity |
| What do the words fibrotic and hyperkeratonic point to? | A callous. |
| What are some associated findings with neuropathic ulcers? | Lacking achilles tendon reflex, warm foot, bounding pulses, ABI >0.9. |
| What are the wound characteristics of a neuropathic ulcer? | Base is pale pink or yellow, even wound margins, rounded or oblong shape over bony prominences, minimal exudate. |
| What are the three features of the Wagner scale? | Depth of ulcer, degree of infection, presence or absence of gangrene and its extent. |
| What are the three features of the University of Texas Diabetic Foot Classification System? | Depth of ulcer, infection, and ischemia. |
| What does hyperglycemia cause in the cells? | Endothelial and smooth muscle cell dysfunction |
| On the foot, what clock positions fall at 12:00 and 6:00? | The toes are always 6:00. The heel is 12:00. |
| What is lymphedema? | Accumulation of lymph fluid in extremities. |
| What is primary vs. secondary lymphedema? | Primary: developmental abnormality Secondary: Resultant of damage to lymph system such as surgery, radiation, etc, |
| What is a positive Stemmers sign? | When you cannot pinch the skin at the base of the second toe secondary to lymphedema. |
| What are the symptoms of lymphedema? | Hyperkeratosis, clear/straw-colored drainage |
| What are some complications of lymphedema? | Fungal infections, depression, lymphatic papillomatosis (lumpy, cobblestone-like projections), lymphorrhea (light, amber colored drainage). |
| What body part is not affected by lipidemia? | Feet. |
| What is lipidemia? | An excess of adiopose tissue that generally presents symmetrically. |
| What is the treatment for lymphedema? | Manual drainage, elevation, high compression wrapping |
| What must be used to effectively remove moisture barrier creams without damaging the skin? | Surfactants. |
| What are the most absorptive dressings? | Hydrofiber dressings. |
| Will a limb with dry gangrene be debrided? | No. |
| What results in pressure injuries? | Either intense or prolonged pressure or pressure in combination with shearing. |
| What is the progression of skin breakdown with a pressure injury? | Hyperemia, tissue ischemia, tissue necrosis, and then ulceration. |
| How fast does tissue ischemia begin? | 2-6 hours of sustained pressure. May disappear in 36 hours if pressure is removed. |
| How fast does tissue necrosis begin? | After 6 hours of continuous pressure. |
| What is shearing? | An internal opposing motion of tissue layers and bone. |
| What does friction without pressure do? | Damages only epidermal and upper dermal layer only. |
| What are the five most common places for pressure ulcers? | Sacrum/coccyx, greater trochanter, ischial tuberosities, heels, lateral malleolus |
| What do wound margins look like in pressure ulces? | Smooth, regular |
| How can a stage 1 pressure ulcer be determined in dark skin tones? | Discoloration, heat, edema, or change in tissue consistency. |
| What defines a stage 4 pressure ulcer? | The visibility or palpability of fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. |
| What is a DTPI? | Deep tissue pressure injury; may be intact or open. May be a blood-filled blister. |
| Do we practice reverse staging? | No. A stage remains at it's deepest level and is just documented as a "healed" stage ______ ulcer. |
| When can a pressure injury be defined as an "unavoidable" pressure injury? | When it was evaluated with risk factors identified, individual plan implemented, and wound plan was monitored, evaluated, and revised. |
| Is higher better or worse on the Norton and Braden scales? | On both, the lower the score, the higher the risk for skin integrity compromise. (Norton = 16 or less) |
| What kind of cleansers should be avoided? | Alkaline, because they can strip the skin's acid mantle. |
| What is the definition of contact inhibition? | When cells stop proliferating because they have come into contact with one another and signaled that healing is complete. |
| What negative impact does hypothermia have on healing? | It inhibits platelet activation and increases bleeding time. |
| What are the general impacts of aging on skin? | Reduction of subQ fat, decrease in estrogen in women, decreased ability to sense light touch and pressure, decreased sebum secretion, decreased capacity to produce vitamin D3. |
| What impact does cancer radiation have on skin? | Radiation causes cell death to fibroblasts, resulting in decreased tensile strength, altered collagen function, and impaired healing. |
| What impact does chemotherapy have on skin? | Results in anemia, neutropenia, and thrombocytopenia. |
| What is pressure redistribution? | Ability of a support surface to distribute load over the contact areas of the human body. |
| Pressure redistribution involves what two concepts? | Immersion and envelopment. |
| What is a mattress overlay? | It goes over a standard mattress |
| What is a mattress replacement? | Replacement of the standard mattress |
| What is an intergrated bed system? | Bed frame and support surface are combined into a single unit. |
| What is a reactive support surface? | It is powered or non-powered with capability to change its load distribution properties only in response to applied load. (Examples: foam, air or gel filled, low air loss, air-fluidized.) |
| What is an active support surface? | Powered surface, changes its load distribution properties either with or without an applied load. (Example: alternating pressure surface.) |
| What is the only FDA-approved enzymatic debriding agent in the US? | Santyl (collagenase) |
| What mitigating step should be taken when applying Santyl to an infected wound? | Use an antibiotic powder beneath the santyl. |
| What is the definition of bottoming out? | Depth of penetration or sinking is excessive, allowing pressure to concentrate over one area with less than 1" of support beneath the person. |
| How do you check for bottoming out? | Slide your hand under the mattress but over the frame of the bed, checking to see if there is at least one inch of inflated surface between your hand and the patient. |
| When is bottoming out assessed? | For air mattress overlays and chair cushions. (Not for mattress replacements or integrated bed systems.) |
| Whe do you use an air-fluidized bed? | Stage 3 or 4 pressure ulcers |
| What is a facility-aquired rate? | The percentage of patients who aquired a pressure injury after admission that is measured at a specific point in time. |
| What is an incidence study? | Percentage of pressure injury-free patients who develop a pressure injury over a specific period of time. |
| What is a prevalence study? | The percentage of patients with a pressure injury in a facility. (Number of PIs over number of patients x 100.) |
| Can you have a full-thickness wound from dermatitis? | No. |
| Where does candidiasis thrive? | Warm, moist environments |
| What type of lesions can you see with candidiasis? | Satellite. |
| When should a product be changed for candidiasis treatment? | 10-14 days so the body doesn't develop resistance. |
| What is the appropriate frequency for repositioning individuals at high risk? | Individualized- no optimal frequency. |
| How many chronic wounds have a biofilm present? | 60-70% |
| What negative impact does a biofilm have on a healing wound area? | It stimulates a chronic inflammatory response. |
| What treatments are indicated for osteomyelitis? | Surgical removal of bone, oral/IV antibiotics (4-8 weeks for acute, 6 weeks for chronic.) |
| What is the gold standard lab result for diagnosing a wound infection? | 100,000 organisms/gm of tissue (10 to the 5th degree guideline) |
| When is the use of an iodine compound antiseptic contraindicated? | Impaired renal failure, history of thyroid disorders, extensive burns, or known iodine senstivity. |
| What is the Payne-Martin Skin Tear Classification? | 1A- Linear, full thickness, in wrinkle or furrow of skin. 1B- Flap, partial thickness, reapproximated to 1mm or less of dermis exposed, 2A- Partial thickness, 75% or more of dermis covered, 2B- Partial, > 25% of flap missing, 3- partial, no flap |
| What is the International Skin Tear Advisory Panel classification system? | |
| What is the only FDA-approved strength of Dakins solution? | 1/4 strength, |
| What is the gold standard for tissue management in diabetic foot ulcers? | Regular, local sharp debridement. |
| What is the damage to tissue caused by gunshot wounds called? | Cavitation. |
| How long does it take for topical analgesics to peak for wound care? | 20-30 minutes, no longer than 60. |
| What are the types of donors? | Auto (self), Allo (another human), Heterograft (non human), Xeno (nonhuman including bone) |
| What can poor nutrition do to skin? | Decrease tensile strength, immune function, and collagen synthesis. |
| What is the definition of malnutrition? | Overnutrition or undernutrition with or without inflammation that leads to a change in body function and composition. |
| What is inflammation? | The body's method of protecting itself. |
| What is pyoderma gangrenosum? | Rare chronic inflammatory disease of unknown etiology with painful skin ulcers. |
| What places a person at risk for pyoderma gangrenosum? | IBS, Chrohns, HIV, Diabetes, RA |
| What does pyoderma gangerosum look like? | Irregular, jagged raised wound margins, most common on legs, halo or erythema, violet-bluish color, nonaggressive/chronic/superficial, painful |
| What is the treatment for pyoderma gangrenosum? | Systemic treatment is required. NO mechanical or sharp debridement. Topical moist healing. |
| What is Kaposi Sarcoma? | Cancer that develops from the cells that line lymph or blood vessels. (Lymphatic or endothelial cells) |
| What causes Kaposi Sarcoma? | HHV-8 (Herpesvirus 8) |
| What makes cases of Kaposi Sarcoma more severe? | HIV/ Immunosuppression. |
| What does Kaposi Sarcoma look like? | Red or purple macules or papules or nodules. Anywhere on skin or mucous membranes. Start small and painless, but open up and cause pain. |
| Treatment for Kaposi Sarcoma? | Freeze with liquid nitrogen, radiation, surgical removal, or intralesional chemotherapy. |
| What is Herpes Zoster? | Shingles. Painful blisters caused by varicella zoster virus. Pain, itching, or tingling may precede their development. |
| What do Shingles look like? | Typically in a single strip along a dermatome, small blisters with dry crusts, crusts fall off in 2-3 weeks |
| What is the treatment for Shingles? | Antiviral meds, pain meds, oatmeal baths, cool wet compresses, calamine lotion. |
| What are sickle cell ulcerations? | Chronic leg ulcers that occur in 25-70% of patients with sickle cell disease. |
| When do sickle cell ulcerations appear? | Typically first in the patient's 20s. |
| Who are more prone to sickle cell ulcerations? | Hispanics or African Americans |
| What are the three major factors of sickle cell ulcerations? | Marginal blood supply to the skin, venous incompetence leading to edema, or minor trauma. |
| Where will you find sickle cell ulcerations? | Common on tibial anterior, dorsum of foot, Achilles tendon, or ankles, with medial malleolus more common than lateral. |
| What do sickle cell ulcerations look like? | Punched out with raised margins and deep bases. May be extensive necrosis initially. Surrounding brown hyperpigmentation and scaling around the ulcer. Extreme tenderness or pain occurs. Secondary infection almost always occurs with staph or pseudomonas. |
| How is sickle cell ulcerations diagnosed? | Hemoglobin electrophoresis, peripheral smear, or CBC. |
| How do you treat sickle cell ulcerations? | Properly fitting shoes, compression therapy, triple antibiotic ointment, sharp or enzymatic debridement, hydrogels, silver ion dressings, skin grafts, bed rest and elevation, hyperbaric |
| What is necrotizing fasciitis? | "Flesh eating disease", caused by bacteria, progressive and rapidly spreading of the deep fascia. |
| What is a good intervention for preventing sickle cell ulcerations in warm weather? | Insect repellent. |
| What kind of diet can help minimize the impact of sickle cell ulcerations? | Low sodium. |
| What meds are given for sickle cell ulcerations? | Pentoxyphiline, zinc, hydroxurea |
| What is the most common bacteria to cause necrotizing fasciitis? | Group A Strep |
| What are risk factors for necrotizing fasciitis? | Obesity, DM, skin injury, renal failure, cancer, IV drug use, immunocompromise |
| Whar does necrotizing fasciitis look like? | Swelling in area, purplish rash, necrosis with bluish/white/dark/mottled and flaky appearance. May have dark-filled blisters. |
| What are the critical symptoms of necrotizing fasciitis that appear in 4-5 days? | BP drops, shock from toxins, or coma. |
| How do you verify necrotizing fasciitis? | Xray, MRI, CT scan |
| How do you treat necrotizing fasciitis? | Antibiotics, surgical debridement, moist wound healing, amputations, HBOT if mixed bacteria. |
| What is pemphigus? | Rare autoimmune disease in which epidermal blistering of skin and mucous membrane. |
| Who typically gets pemphigus? | Middle aged or older individuals. |
| What do most cases of pemphigus start as? | Blisters in the mouth and skin. |
| What can pemphigus lead to? | Death. |
| How do you diagnose pemphigus? | Nikolsky's sign: When skin is rubbed, the top layer slips away from the bottom. Biopsy. Tzanck test. |
| How do you treat pemphigus? | Similar to burns. May use mouth lozenges. Antifungal/antibiotics, corticosteroids, medications containing gold or immunosuppressants. May use plasmapheresi |
| What is a fistula? | An abnormal passage between two or more structures or spaces. |
| What are contributing factors to fistulas? | IBS, cancer, diverticulitis, sepsis, malnutrition |
| How are fistulas classified? | Location, output (high = >500 ml/ day, low = <500 ml/ day.) |
| What is the difference between fistulas and dehisced wounds? | Fistulas drain urine, stool, bowel contents. Wounds drain serosanguineous fluid. |
| What are goals of management for fistulas? | Containment of effluent, perifistular skin protection, odor control, patient comfort and mobility. |
| What is a vesicocutaneous fistula connecting? | Bladder to skin |
| What is an enterovaginal fistula connecting? | Small bowel to vagina. |
| What are the methods for containing a fistula? | Ostomy pouches, wound drainage systems, colostomy caps |
| When would you consider a non-pouching fistula management? | Low output (less than 45 cc in 24 hours), no odor, or when contours of the skin make pouching impossible. |
| What can be used to protect the skin around fistulas? | Petroleum or zinc-based ointments. |
| What is a consideration if packing fistulas? | Leave a 2 inch tail of dressing out. |
| What kind of drainage do you see with fistulas and what pouch do you use for each? | Watery and thin (use a pouch with a spout or tube closure) or thick and pasty (use a pouch with an open-end clamp.) |
| What are the priorities for palliative wound care? | Give the patient control of their life and facilitate independence, dignity, and comfort. |
| What is the secondary goal for palliative wound care? | Heal the wound. |
| What are the causes of palliative wounds? | Tissue death and breakdown, anaerobic bacteria |
| What are the interventions for palliative wounds? | Removal of necrotic tissue, Metronidazole, charocal dressings, ostomy pouches, wound cleansing or bathing. |
| What is the treatment of bleeding for palliative wounds? | Direct pressure, ice, silver nitrate, gelfoam sterile sponges, soaking off of dressings, and non-adherent dressings when possible. |
| What is a Kennedy Terminal Ulcer? | An unavoidable pressure injury that may occur during the dying process. |
| What does a Kennedy Terminal Ulcer look like? | Pear shaped, sudden onset as blister/abrasion/stage 2 that rapidly devolves, usually on sacrum, ranges in color from red to yellow to black, irregular borders. |
| Who typically develops Kennedy Terminal Ulcers? | Older terminal patients (not pediatric). |
| What are fungating malignant wounds? | Wounds that occur when a tumor infiltrates the epidermis. Can occur from lymphatics or bloodstream. |
| What are the most frequent locations for fungating malignant wounds? | Oral and breast cancers. |
| What are the characteristics of fungating malignant wounds? | Cavity, open area, skin nodule, or nodular growth extending from surface of skin. May become a nodular fungus or cauliflower shaped lesion. If ulcerating, may form crater-like appearance. Discrete, non-tender, skin toned/ pink/ violet-blue/ brown-black. |
| What is the goal of managing fungating malignant wounds? | Palliative management. Moist wound healing, dressing that doesn't require frequent changes, treatment of yeast, extreme caution and discernment with sharp debridement. |
| What is a marjolin ulcer? | A squamous cell carcinoma that develops in skin affected by chronic inflammation. May very well reoccur. |
| What BMI is considered "obese"? | 30 and over. |
| What is the mortality rate that is common after significant wound loss? | 9% to 38% within 1-2.5 years. |
| What is the peak recommended postprandial capillary glucose level? | <180 |
| What timespan does an A1C measure? | 8-12 weeks |
| Should a nurse crush and sprinkle metronodazole into a wound surface? | It can be done, then covered with a petroleum gauze and a dry bulky dressing. |
| What is the Metronidazole dose for wound odor interventions? | 200 mg twice daily or 0.75% topical gel daily. |
| What percentage of oral intake can indicate poor nutritional habits? | Less than 50-75% of foods, or else a clear liquid diet for 3 days or more. |
| What is the only nutrient that contains Nitrogen? | Protein. |
| What do vitamins C and B do? | C- Collagen and fibroblast formation B - Making energy from glucose. |
| What minerals are needed for good nutrition? | Iron, copper, zinc |
| What fluid intake is recommended for wound healing? | 30 ml / kg body weight or 1 ml/kcal consumed daily. |
| What are the medications used for appetite stimulation? | Oxandrolone, Megestrol, Dronabinol (cannabis), Eldertonic |
| What two types of dressings should not be combined? | Hydrogel and alginates. |
| When are surfactant or antimicrobial cleansers indicated? | Wounds with debris, confirmed infection, suspected infection, or suspected high levels of bacterial colonization. |
| What are the contraindications for a composite dressing? | There are none! :) |
| What are the underlying causes of marjolin ulcers? | Burns, venous ulcers, osteomyelitis |
| What does a marjolin ulcer look like? | More often on lower extremity. |
| How do you confirm a marjolin ulcer? | Biopsy. |
| What is the treatment for a marjolin ulcer? | Excision or amputation. |
| What is a furuncle? | A boil secondary to damage to hair follicle with infection |
| What does a furuncle look like? | Nodule or pustule, discharges necrotic tissue and pus. |
| What is the treatment for a furuncle? | Warm moist compresses, I&D, systemic antibiotics if larger and do not respond to topical care, culture if on nose or face. |
| Is a contact layer dressing non-permeable? | No. They are porous, allowing drainage to pass through into a secondary dressing, which is a REQUIRED second step. |
| When is a foam dressing indicated? | Minimal to heavy drainage, red/granular wounds, softened necrotic tissue, shallow draining wounds, cavity to fill dead space, under compression. |
| What is a gelling fiber dressing? | Highly absorbant dressings that form a gel to support moist wound healing. |
| What is the color progression of a Kennedy? | Red to yellow to black |
| What type of ulcer is from excessive calcium in blood, common in dialysis patients? | Calciphylaxis. |
| What types of dressings are good alternatives to wet-to-dry? | Calcium alginate, hydrofiber, hydrogel impregnated gauze, or foam cavity dressings. |
| What is the mechanism of action for a hydrogel? | It donates moisture to a wound. |
| What type of dressing can provide cooling for a painful wound? | Hydrogel. |
| What type of dressing is indicated for pressure injuries, diabetic foot ulcers, venous leg ulcers, traumatic wounds, partial-thickness burns, or skin grafts? | Silicone. |
| What are the two types of negative pressure? | Gauze or foam |
| What phrase should be applied for tape removal? | "Low and slow". Stay close to the skin, apply counter-pressure to the skin, and go slowly. |
| What are Montgomery straps? | Medical-grade adhesive tape panels that hold frequently changed dressings in place. |
| What is a cohesive bandage? | One that sticks to itself and not skin. |
| What are contraindications for negative pressure wound therapy? | Dry wounds, fistuals to organs or body cavities, eschar or more than 10% slough, untreated osteomyelitis, malignancy, EXPOSED BLOOD VESSELS OR ORGANS. |
| When is Regranex indicated and not indicated? | Indicated= lower extremity diabetic neuropathic ulcers that are perfused and extend into the SubQ or lower. NOT indicated = Pressure injuries, venous stasis ulcers, shallow or ischemic diabetic ulcers. |
| How thick should Regranex be? | 1/16 of an inch |
| What should Regranex be covered with? | Saline-moistened dressing for appox 12 hours. |
| When should an antifungal regimen be changed out? | After 10-14 days so patient does not develop resistance. |
| What is the difference between a cellular and an acellular product? | Cellular = contain living cells *usually fibroblasts and keratinocyes Acellular = Contain no cells but have a porous matrix that stimulates the production of growth factors. |
| What is treatment time for e-stim? | 60 minutes 5-7 times a week. |
| What are the three sources of Xenografts? | Bovine (cows), Porcine (pigs), and Marine (fish) |
| What is Hyperbaric oxygen therpay? | Patient breathes 100% oxygen at pressure greater than sea level for 60-90 minutes. |
| What is the goal of hyperbaric oxygen therapy ? | Increase amount of pressure dissolved o2 that is delivered to the body tissues. |
| What are the indications for hyperbaric oxygen therapy? | Gas gangrene, problem/ compromised wounds. arterial insufficiency, osteomyelitis |
| What indicates possible sepsis after cellulitis? | Rapidly increasing pain, hypotension, delirium, skin sloughing, bullae and fevers. |
| What is the mechanism of a long stretch bandage? | Stretches with movement, which causes a lower level of pressure when the muscle is active and a higher amount when the muscle is at rest. |
| What are the best ways to protect yourself in clinical practice? | Provide individualized and consistent care, and document everything. |
| What is the ABI that marks a contraindication to compression therpay? | Less than 0.5. |
| How high should a compression wrap go on the leg? | To 1 inch below the knee. |
| What tension and overlap are indicated for compression wraps? | 50% tension, 50% overlap. |
| What kind of dressings are often used under compression? | Collagen. |
| What is clinical limb ischemia (CLI)? | CLI is the most severe manifestation of PAD and presents with resting pain, ulceration, or gangrene, with an ABI of less than 50 or toe pressure less than 30. |
| What are the three kinds of diabetic foot ulcers? | Neuropathic, ischemic, and neuroischemic (most common). |
| When should a nurse remove retention sutures? | Trick question. Only physicians or mid-level providers (PA, APRN) should do this. |
| What type of wound tends to be torn or jagged and caused by trauma? | Lacerations |
| What is an abrasion? | A superficial wound caused by a mechanical process against the skin (friction/ shearing) |
| What is another word for an avulsion. | Degloving. |
| What is a thermal burn? | Residential fire, auto accident, or scald. |
| What is a chemical burn? | Contact with acids, alkalis, or vesicants |
| What is an electrical fire? | Contact with faulty electrical wiring, cords, or high-voltage power lines. |
| What is a superficial burn? | Damage limited to epidermis. Erythema, hyperemia, tenderness, and pain. |
| What is a superficial partial-thickness burn? | Damage extends through epidermis into papillary (superficial) dermal layer. Large blisters, edema, pain. |
| What is a deep partial-thickness burn? | Extend deeply into second layer of skin, can quickly evolve into full thickness burn. Splotchy red or waxen, white, wet, no blisters. |
| What is a full thickness or subdermal burn? | Damages muscle, bone, or interstitial tissue. Deep red, black, or white. Painless. Exposed subQ fat layer. Grafting is required. |
| When is immediate transfer to a burn unit indicated? | Partial thickness burn in adults of >15% BSA or children/ elderly in >10% BSA. Full thickness of >5% BSA. Burns to face, hands, feet, perineum. All burns that are electrical or inhalation, or circumferential when pain control is needed. |
| What is a shortcoming of silver sulfadiazine? | It cannot penetrate eschar well. |
| What is an escharorotomy? | When sub-eschar edema develops under burn tissue, pressure increases, so the eschar is split with a scalpel to reduce the pressure. |
| When is dry desquamation seen? | 3-4 weeks after radiation |
| How does dry desquamation present? | Dry, itchy, peeling, flaky |
| When is moist desquamation seen? | After 5-6 weeks of radiation |
| How does moist desquamation present? | Erythemous, serous exudate, nerve exposure, pain, blisters, vesicles. |
| What is delayed or late radiation reaction? | Occurs at least 6 months after treatment. Appears as pigment changes, permanent hair loss, telangiectasia, fibrous changes, atrophy, ulceration. |
| What is radiation recall associated with? | Chemo. |
| What should NOT be done with radiation recall? | Rubbing of the skin. |
| What products should be avoided with radiation recall? | Petroleum jelly-based products. |
| What is the treatment for radiation recall? | Moist wound healing |
| What does calciphylaxis look like? | Sudden, rapidly-progressing, violet or erythematous, mottled skin changes (called livedo reticularis), black in the center with star-shaped lesions. Most occur on lower extremities. May have multiple lesions of variable ages. |
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