Basic Wound Care

Question 1

The most common wounds that are
treated by a wound care Physical
Therapist are:

Answer 1

• Stage III, IV pressure ulcers (pressure injury).
• Diabetic wounds
• Chronic wounds
• Venous and/or arterial wounds
• Extremity wounds with edema
• Non-healing surgical wounds

Question 2

What are the members of the wound care team?

Answer 2

• a physician
• nursing
• physical therapists
• registered dietitians
• case managers
• orthotics/prosthetists
• podiatrists

Question 3

outer most layer
formed by keratinocytes
regenerates every 4-6 weeks
protects against water loss and physical damage
sensation

Answer 3

epidermis

Question 4

Components of the Dermis layer

Answer 4

• collagen
• elastin fibers
• extracellular matrix
• blood/lymphatic vessels
• nerve endings
• hair follicles
• sebaceous/sweat glands
• fibroblasts

Question 5

Components of the SubQ/Hypodermis layer

Answer 5

• adipose and connective tissue
• major blood/lymphatic vessels
• nerves

Question 6

What are the functions of the skin?

Answer 6

Protection
Excretion
Sensory Perception
Thermoregulation
Metabolism
Absorption

Question 7

Which vitamin does the skin synthesize?

Answer 7

Vitamin D

Question 8

Type of wound closure that involves a delayed primary closure. used in case of infection.

Answer 8

Tertiary Intention

Question 9

Migration of cells over the wound edge, begins to

occur within 24 hours of injury.

Answer 9

Epithelialization

Question 10

Formation of a new tissue and capillaries around the

wound edge-usually pink in color.

Answer 10

Granulation

Question 11

Phase 1: Inflammation

Answer 11

• 1-5 days
• edema and necrosis
• initial vasoconstriction
• phagocytes cells to clean wound

Question 12

What are some causes for abnormal inflammatory responses in wounds?

Answer 12

• Immunosuppressive medications
• Arterial Insufficiency
• Medical conditions that alter the immune response

Question 13

Phase 2: Proliferation

Answer 13

• 3-20 days
• fibroblasts secrete collagen (type III)
• angiogenesis
• granulation
• epithelialization

Question 14

Phase 3: Remodeling / Maturation

Answer 14

• 9 days to 2 years
• type III collagen converts to type I
• decreased capillaries
• scar tissue contracts and matures

Question 15

Involves some degree of tissue loss, needs a second change to get it right. Formation of granulation tissue to fill in scar.

Answer 15

Secondary Intention

Question 16

In the early inflammation stage
immediately following an injury, which
comes first? Vasoconstriction or Vasodilation?

Answer 16

Vasoconstriction

Question 17

The development of new blood vessels

Answer 17

Angiogenesis

Question 18

Type of wound that involves pain, swelling and discoloration. The skin is not broken.

Answer 18

Contusion

Question 19

Mass of blood usually caused by a break in a blood vessel

Answer 19

Hematoma

Question 20

Darkening of skin due to accumulation of iron-containing pigment. Common in venous ulcers

Answer 20

Hemosiderin staining

Question 21

What should you evaluate in the Peri-wound area of a wound?

Answer 21

– Sensation
– Peripheral Pulses
– Skin temperature
– Dryness of surrounding tissue

Question 22

Abnormal exudation that are signs of infection.

Answer 22

• seropurulent: cloudy, opaque, yellow or tan, thin watery

- Purulent: yellow or green, thick, viscous

Question 23

Intrinsic factors that cause abnormal wound healing

Answer 23

– COPD-Hypoxemia
– DM: loss of protective sensation
– CA: Decreased Immune Function
– Peripheral artery disease or Venous 
insufficiency

Question 24

Medications that can cause poor or prolonged inflammatory response

Answer 24

anti-inflammatory
immunosuppressive
steroids
anti-coagulants
oral contraceptives

Question 25

Signs of Infection

Answer 25

- bright red streaks - change in drainage - swelling - increased pain - fever, nausea, fatigue or loss of appetite

Question 26

abnormal passage between an | organ or vessel and another organ, vessel,or area

Answer 26

Fistula

Question 27

Most important external factor in optimal | wound healing

Answer 27

Moisture

Question 28

Nutrients necessary for wound healing

Answer 28

- iron - vitamin B12 - vitamin C - zinc - high protein - folic acid

Question 29

Pressure relief support surfaces

Answer 29

- air and foam mattresses - avoid synthetic sheep skin pads, donuts - natural sheepskin may assist in prevention - use a pressure redistributing seat cushion

Question 30

Explain the rule of 30 for Pressure Injury Prevention

Answer 30

Positioning: Rule of 30 (>30 = increased shearing) ˃ In supine: 30 degrees incline bed ˃ In sidelying: 30 degrees offloaded, so weight on the buttocks, not the bones- use wedges and pillows to protect all bony prominences

Question 31

Intact skin ˃ Non-blanchable redness in localized area (usually bony prominence) ˃ Different that surrounding skin May be different color May be painful, firm, soft, warmer, cooler ˃ Darkly pigmented skin: May be difficult to detect

Answer 31

Stage 1 Pressure Injury

Question 32

Partial thickness loss of dermis shallow open ulcer with red-pink wound bed, without slough. Shiny or dry without bruising

Answer 32

Stage 2 Pressure Injury

Question 33

Full thickness tissue loss subcutaneous fat may be visible. Bone, tendon, muscle not exposed. Slough possible but does NOT obscure depth of tissue loss

Answer 33

Stage 3 Pressure Injury

Question 34

Full thickness tissue loss with visible but bone, tendon or muscle exposed. Slough and eschar present. Often has tunneling and undermining. Can extend into muscle

Answer 34

Stage 4 Pressure Injury

Question 35

Full thickness skin or tissue loss - depth unknown. | Depth completely obscured by slough/eshcar.

Answer 35

Unstageable Pressure Injury