Integ. Case Study Prep

Question 1

With the Clock Method, how is the wound measured?

Answer 1

Length x Width x Depth in cm

• Length: measurement from “head to toe” direction (from 12 o’clock to 6 o’clock)
• Width: perpendicular to length. Usually measured at its max width from 9 o’clock (ish) to 3 o’clock (ish)
• Depth: Using a cotten tipped applicator, bottom of wound is probed until max depth is recorded

Question 2

With Tissue Types, what is Eschar?

Answer 2

• Non-Viable/Nectrotic tissue
• Usually a black/brown appearance
• Varies in texture (hard, dry)

Question 3

With Tissue types, what is Slough?

Answer 3

• Non-viable subcutaneous tissue
• Result of autolytic debridement
• Soft yellow tissue

Question 4

With Tissue types, what is Granulated tissue?

Answer 4

• Viable tissue
• Usually noted to be a “beefy red” appearance
• Composed of ECM and capillaries

Question 5

Are muscle and bone Viable or Non-Viable tissue?

Answer 5

Both can be non-viable tissue
- Based on nuritional characteristic

Question 6

What tissue type are Tendons?

Are they Viable or Non-viable?

Answer 6

These can be non-viable
- They can be visualized with full thickness wounds
- Viable tendon must remain moist to prevent desiccation or dryness as this would decrease the viability of the tissue
(Still characterized as viable if it still contains is surrounding peritenon sheath, if it looks shiny)

Question 7

What tissue type are Adipose Tissue?

Are they viable or non-viable?

Answer 7

This can be non-viable
- Characterized by shiny globules when viable and has a dull yellow appearance when non-viable due to delayed vascularization
- Adipose tissue is slow to vascularize which may cause it to be non-viable

Question 8

What is Hypergranulation tissue?

Answer 8

• This is characterized as granulation tissue that overrides the tissue surface and is a sign of abnormal healing
• Although red which is generally referred to as healthy tissue will cause an inability to heal as the edges will not be able to approximate up over the edges of the granulation tissue

Question 9

In reference to the amount of drainage, what does scant mean?

Answer 9

Small remnant of drainage on dressing after removal

Question 10

In reference to the amount of drainage, what does minimal drainage mean?

Answer 10

~ 25% of the dressing is covered

Question 11

In reference to the amount of drainage, what does Moderate drainage mean?

Answer 11

~ 50% of the dressing is covered

Question 12

In reference to the amount of drainage, what does Heavy drainage mean?

Answer 12

~ 100% of the dressing is covered

Question 13

In reference to the amount of drainage, what does Copious mean?

Answer 13

Multiple layers of dressing are covered

Question 14

In reference to the amount of drainage, what does Strike Through mean?

Answer 14

Drainage visable through the last layer of dressing (unable to be contained by the dressing)

Question 15

In reference to the Type of Drainage, what is Serous?

Answer 15

Clear serum
- Normally occurs in the inflammatory stage of healing

Question 16

In reference to the Type of Drainage, what is Sanguineous?

Answer 16

“Bloody”

Question 17

In reference to the Type of Drainage, what is Serosanguineous?

Answer 17

A mixture of serous and sanguinous
(Clear and bloody)
- Usually more pinkish

Question 18

In reference to the Type of Drainage, what is Purulent?

Answer 18

Thick, and viscous, may be smelly; “pus”

Question 19

When removing the dressing of a wound sometimes the wound will have an odor. What type of odor is Pseudomonas?

Answer 19

This is characterized as sweet odor
- “Corn Tortilla”

This is also a type of bacteria that has a green appearance

Question 20

When removing the dressing of a wound sometimes the wound will have an odor. What type of odor is Wet Gangrene?

Answer 20

This is characteristically a foul odor

Question 21

After a diagnosis is obtained, we establish a prognosis. What takes place in the prognosis?

Answer 21

• Predicted expected outcomes
• Estimation of therapy frequency/duration

Common prognosis:
-Wound closure
-Clean and stable wound
-Wound not expected to improve

After the prognosis, goals are made (using SMART)

Question 22

With ABI, what does the value 1.00 - 1.4 mean?

Answer 22

Normal
- Adequate Blood supply

Question 23

With ABI, what does the value > 1.4 mean?

Answer 23

Non-compressible arteries

This is still considered abnormal

Question 24

With ABI, what does the value 0.91- 0.99 mean?

Answer 24

Borderline Occlusion

Abnormal

Question 25

With ABI, what does the value 0.80 - 0.90 mean?

Answer 25

Mild Occlusion - Compression Therapy = No greater than 30-40 mmHg | Abnormal

Question 26

With ABI, what does the value 0.50 - 0.79 mean?

Answer 26

Moderate Occlusion - Reduced Compression Therapy = No greater than 23-30 mmHG | Abnormal

Question 27

With ABI, what does the value ≤ 0.49 mean?

Answer 27

Severe Occlusion - Any compression therapy is **contraindicated** - Vascular Referral

Question 28

What are the Clinical Presentations of Arterial Insufficiency wounds?

Answer 28

- Round and small with smooth regular borders ("Hole Punch") - Lacks in granulation tissue (usually pale) - Pink Periwound - Usualy occurs on the distal digits first - Painful especially with elevation - May have hair loss - May have muscle atrophy - Dependent Hyperemia may be present, which may be seen during the Rubor of Dependency Test

Question 29

With Aterial Insufficiency Treatment, what can be done for Protection?

Answer 29

- The application of PRAFO (Protection, Relief, Ankle, Foot, Orthosis) - Heel Cushions - Pressure relief - Clean/Sterile bandaging

Question 30

With Aterial Insufficiency Treatment, (other than protectio) what are other treatment options for the patient?

Answer 30

- Infrared Light - Debridement (stable eschar is NOT to be debrided!)

Question 31

What are the Clinical S/S of Venous Insufficiency? | {Location, onset, appearance, pain, etc}

Answer 31

- Location: Above Malleoli (Gaiter area) - Onet: Insidious - Appearance: **Uneven** edges, shallow, little eschar - Periwound: Increased thickness, hemosidian staining - Moderate to Copious serous, purulent drainage (usually this happens if there is no arterial insufficiency) - Pain: minimal

Question 32

What is the Gold Standard Treatment for Venous Insufficiency?

Answer 32

**Compression** - Not for use with active CHF or excessive PAD (Severe arterial insufficiency), **CONTRAINDICATION!!!!** - Spiral -50% stretch and 50% overlap -Use for patients who are bed bound or do not require a lot of compression - Figure 8 -50% stretch and 50% overlap -Provides 2x as much compression as spiral -Used for patients who are regularl ambulatory and have good ABI values

Question 33

# According to the NPUAP What is stage 1 of Pressure Injury?

Answer 33

*Superficial* Nonblanchable erythema of intact skin

Question 34

# According to the NPUAP What is stage 2 of Pressure Injury?

Answer 34

Partial-thickness loss with exposed dermis

Question 35

# According to the NPUAP What is stage 3 of Pressure Injury?

Answer 35

Full thickness skin loss; bone/tendon/muscle **NOT** exposed - Evidence of **necrotic tissue automattically characterizes the wound as stage 3**

Question 36

# According to the NPUAP What is stage 4 of Pressure Injury?

Answer 36

Full thickness skin and tissue loss; with exposed fascia/bone/tendon/muscle

Question 37

# According to the NPUAP What is the Unstageable Pressure Injury?

Answer 37

Obscured full-thickness skin and tissue loss; **base of wound covered with slough or eschar** - Until wound is debrided, the full depth cannot be ascertained

Question 38

# According to the NPUAP What is the Suspected Deep Tissue Injury Pressure Injury?

Answer 38

Persistent non-blanchable deep red, maroon or purple discoloration

Question 39

What Interventions can be done for Pressure Injuries?

Answer 39

**Pressure Relief**: - PRAFOs (Protection Relief Ankle Foot Orthosis), Weightshifting/Repositioning **Pressure redistribution support surface** - Roho cushions - Air mattresses - Pressure mapping systems **Care for moisture prone areas** - Prevent "maceration" - Barrier creams **Reduce friction/shearing forces**

Question 40

# Interactive Dressing What are Film Dressings?

Answer 40

- These dressings are coated with acrylic adhesive - They are not absorbent but are permeable to oxygen and air, but impermeable to microorganisms - **They are flexible, elastic, extendsible and transparent** (So they can adjust to the movement of the body part and we can continue to assess the wound without removing the dressing)

Question 41

What are the Effects and Indications of using Film Dressings?

Answer 41

- They provide a moist wound environment - They assist with autolytic debridement - Provide protection for microorganisms - Provide gaseous exchange of O2, CO2 and water vapor -Disadvantage is that they are not very absorbant, so they can promote the accumulation of excessive exudate Indications: - Minor Burns - Simple injuries (abrasions, skin tears) - Post-op dressing

Question 42

# Interactive Dressing What are Foam Dressings?

Answer 42

- These are made of polyurethane, soft, open sheets - They may have 1 or more layers - Similar in appearance to hydroactive polymer products - May have a waterproof backing or be impregnated with charcoal

Question 43

What are the Effects of Foam Dressings?

Answer 43

- Provide moist environment - Provide high absorbency (for moderate/high exudate) - Confrom to body shape - Provide protection and cushioning - It does NOT adhere to the wound - Provides thermal insulation - Transmits moisture vapor out of dressing to avoid maceration

Question 44

What are the Indications for Foam Dressings?

Answer 44

- When there is Moderate to High Exudating wounds - Superficial and cavity types of wounds - LE ulcers, such as venous ulcers - Pressure injuries

Question 45

# Interactive Dressing What are Hydrogels?

Answer 45

- This is made up of Complex organic polymers with high water content - They are 3 dimensional, water swollen structures 2 types: - Amorphous: Free-flowing, easily fills a cavity space - Sheet: Thin, flexible sheets that swell as they absorb fluid

Question 46

What are the Effects of Hydrogels?

Answer 46

- They provide moisture to dry wounds - They can provide or absorb moisture - They aid in autolytic debridement - Conform to body shape - Does NOT adhere to wound

Question 47

What are the Indications of using Hydogels?

Answer 47

- Dry and minimally draining wounds - LE wounds, such as arterial ulcers - Pressure injuries, Stages 2-4 - Full or partial thickness wounds - Over tendons and other tissues to prevent tissue dehydration - Infected and necrotic wounds

Question 48

# Interactive Dressing What are Hydrocolloids?

Answer 48

- These are dressings that are a combination of gel-forming polymers with adhesives with a backing of a polyurethane film or a foam - Wound exudate combines with the polymers to create a soft gel in the wound - Dressing only adheres to surrounding tissues, not the wound itself

Question 49

What are the effects and indications for Hydrocolloids?

Answer 49

- Provide a moist environment - Aid in autolytic debridment - Conform to body shape - Protect from microorganims - Provide a waterproof surface - Not indicated for heavily exudating or deep cavity wounds Indications: - Superficial and small cavity wounds - LE wounds, burns, pressure injuries

Question 50

# Interactive Dressing What are Alginates?

Answer 50

- These are made of calcium or calcium/sodium salts of alginic acids from **seaweed** - Available as textile fiber sheets or a loose packing ribbon - Produce a hydrophilic gel in the wounds - Provide calcium ions to the wound to promote hemostasis

Question 51

What are the effects of Alginate dressings?

Answer 51

- Provide a moist environment - High absroptive capacity - Conform to body shape - Protect from microbial contamination - Promotes hemostasis - Does not adhere to wound

Question 52

What are the indications to use Alginates?

Answer 52

- With Heavily exudating wounds, including sanguinous exudate - Infected wounds - Cavity wounds - LE wounds - Pressure injuries - Donor sites

Question 53

# Interactive Dressing What are Hydroactive Dressings?

Answer 53

- These are multiple layers of highly absorbent polymer gel with adhesive backing - Similar to hydrocolloidsm, but do not form gel in wound - Semipermeable - Adhere to surrounding skin - Available in various forms, including cavity fillers, foams, and thin types

Question 54

What are the effects of Hydroactive Dressings?

Answer 54

- Provide moist enviornment - Aid in autolytic debridement - High absorbency - Waterproof surface - Regain their shape when stretched - Semipermable to water vapor

Question 55

What are the Indications for using Hydroactive Dressings?

Answer 55

- Moderate to heavily exudating wounds - LE ulcers, such as venous ulcers - Pressure injuries - Wound around joints

Question 56

What do Collagen Matrix Dressings do?

Answer 56

- Contain collagen that stimulate fibroblast activity

Question 57

What do Hydrofiber dressings do?

Answer 57

- These are activated by moisture, plymers absorb and trap moisture in their structures -Look like alginates

Question 58

What is **Autolytic** Debridement? What are the steps for this?

Answer 58

**Endogenous healing** of the wound Steps: - Cleansing - Maintance of a moist environment - Cross hatch eschar - Cover with appropriate dressing to promote healing

Question 59

What is **Enzymatic** Debridement? What are the steps for this?

Answer 59

**Enzymes used to prepare the wound bed by allowing them to break down the nonviable tissue** Steps: - Obtain physicians order for a collagenase - Clease wound appropriately - Apply enzyme directly to the nonviable tissue - Cover with appropriate dressing (moist gauze) - Apply 1x/2x per day

Question 60

What is **Mechanical** Debridement? What are the different types?

Answer 60

This refers to some **outside source to remove the non-viable tissue** - Wet to Dry Gauze dressings - Scrubbing - Hydrotherapy - Low frequency ultrasound - Pulsatile Lavage (Pressurized fluid irrigation) -Gold Standard = 35-50cc syringe with a 19 gauge catheter to create 4-9psi **avoid > 15 psi**

Question 61

What is **Sharp** Debridement? What are the steps for this?

Answer 61

- The most rapid form of debridement - May require multiple/sequential treatments to clean the wound bed Steps: - Pre-medicate as needed with lidocain/oral medication under supervision of physician - Assemble necessary equipment including agents to stopn excess bleeding - Clease wound - Use scalpel blades (No. 10 or No. 15), curettes, scissors and/or forceps for removal or nonviable tissue

Question 62

# Identifying Factors: Abnormal Lab Values If a person has increased HbA1C%, how may this affect wound healing? ## Footnote What is considered Normal?

Answer 62

*Blood sugar* - If the persons HbA1C% is increased this may indicate delayed wound healing ## Footnote Normal is ≤5.7%

Question 63

*Examples of Goals*

Answer 63

- “In 2 weeks, patient will demonstrate correct wound dressing application with independence” - “In 4 weeks, wound will demonstrate 50% less necrotic tissue in order to improve wound healing and increase functional mobility”