Download WOCN Wound Exam Question With Verified Solution 2024 Goals of wound assessment - ✔✔1. Det and more Exams Nursing in PDF only on Docsity!
WOCN Wound Exam Question With Verified
Solution 2024
Goals of wound assessment - ✔✔1. Determine etiologic factors
- Assess systemic factors/comorbidities
- Assess wound to determine phase of healing
- Determine goals of topical therapy Why does hyperglycemia affect wound healing? - ✔✔Impairs leukocyte function and negatively impacts collagen syntehesis, development of tensile strength, epithelial resurfacing What BG parameters should be maintained for wound healing? - ✔✔BG <180 for leukocyte function; <140 for healing A1C <7 for most, <8 if hx of severe hypoglycemia, advanced comorbidities, limited life expectancy Why is nutrition relevant to wound healing? - ✔✔Muscle or SubQ wasting increases risk of pressure/shear damage malnourished pt unable to synthesize and cross-link collagen normally protein deficiency increases risk of infection What effect do low zinc levels have on wound healing? - ✔✔compromise collagen synthesis/crosslinking
What amino acids are essential for collagen synthesis? What is the effect of stress on these amino acids? - ✔✔Glutamine and l-arginine Not adequately produced during times of physiologic stress What weight trend suggests nutritional deficiency? - ✔✔Unplanned weight loss =>2.5% of usual weight in 30 days or =>10% within 180 days BMI <18. What serum albumin level indicates malnutrition? - ✔✔<3.5 g/dl What serum transferrin level indicates malnutrition? - ✔✔<100mg/dl What serum prealbumin level indicates malnutrition? - ✔✔<19. What total lymphocyte count level indicates malnutrition? - ✔✔< What are s/s of nutritional deficits? - ✔✔skin rashes, cracks in mucous membranes, edema, muscle and subQ tissue wasting, nonhealing wounds, dry/pluckable hair, dry flaky itchy skin What is the suggested caloric intake? - ✔✔ 30 - 35 cal/kg body weight What is the suggested protein intake? - ✔✔1.25-1.5 g/kg body weight
Stratum spinosum - desmosomes (cell to cell junctions) Stratum germinativum - dermal-epidermal junction What is the Basement Membrane Zone? - ✔✔Dermal-epidermal junction What are the components of the dermis? - ✔✔Papillary dermis: papillae interlock with rete ridges, capillary loops, sensitive to point pressure Reticular dermis: mostly type 1 collagen, vasculars, and lymphatics What structures of the skin can regenerate? - ✔✔Epidermis and parts of the dermis What structures of the skin heal by scar formation? - ✔✔Epidermal appendages, Subcutaneous tissue/fascia/muscle How is newborn skin different? - ✔✔No scars up to 2nd trimester 30% thinner skin Faster epidermal turnover How is premature infant skin different? - ✔✔Very thin, increased fluid loss, functional stratum corneum at 30-32 weeks What problems may arise with infant skin? - ✔✔increased permeability, increased MARSI risk, extravasation, diaper dermatitis
How do you mitigate MARSI risk in infants/elderly? - ✔✔avoid tape or use hydrocolloid base or silicone adhesive, no alcohol removers only mineral oil, petroleum, silicone (preferred), and citrus) How do you mitigate extravasation in an infant? - ✔✔Hyaluronidase OR phentolamine if vasoconstrictor How do you mitigate diaper dermatitis? - ✔✔Higher pH Use petroleum base for mild erythema and zinc oxide for denuded skin sever denudation - carboxymethylcellulose/petrolatum/zinc oxide (Ilex) What bathing considerations must you take for premature infants? - ✔✔<30 weeks bathe with water only for 2 weeks What are common issues with older skin? - ✔✔Thinner, collagen shrinks and causes wrinkles Rete ridges and dermal papillae flatten - increased risk for tears/stripping Reduced sebaceous and sweat glands - dry skin Erratic/decreased melanin production Decreased sensation - increased trauma risk Loss of SubQ tissue - increased shear and decreased insulation Increased malignant lesions - refer to derm
Who are humectants for? - ✔✔Only for xerosis - not for macerated and sometimes not for fragile skin Which tissue layer is most susceptible to ischemic damage? - ✔✔Muscle/fascia layer What is a macule - ✔✔Flat spot of color change less than 0.5cm in diameter What is a papule - ✔✔Flat spot of color change greater than 0.5cm in diameter What is a patch? - ✔✔Raised spot of color change less than 0.5cm in diameter What is a plaque? - ✔✔Raised spot of color change greater than 0.5cm in diameter What is a blister? - ✔✔Serous fluid trapped under skin less than 0.5cm in diameter What is a bulla? - ✔✔Serous fluid trapped under skin greater than 0.5cm in diameter What is erythema? - ✔✔Generalized redness What is denudation? - ✔✔Loss of superficial skin layer
What is crusting? - ✔✔Scab of dried exudate of body fluid, blood, or pus What is granulation? - ✔✔proliferating tissue made of capillary networks, collagen, and other connective substances What is slough? - ✔✔Loose, stringy, nonviable tissue What is eschar? - ✔✔Thick, leathery, necrotic tissue What is undermining? - ✔✔Tissue destruction underlying intact skin along wound margins What is tunneling? - ✔✔Area of tissue loss extending in any direction from edge of wound What is the normal water content of the skin? - ✔✔ 10 - 15% What is friction skin damage? - ✔✔Mechanical disruption of surface layer of skin Where does friction skin damage occur? - ✔✔under restraints, blisters on heels, surface damage on butt What precedes friction skin loss? - ✔✔Erythema, tenderness
How can you avoid skin tears? - ✔✔avoid tape moisturize - supple skin protect arms with wrap (ensure no compression) pad bedrails, wheelchairs, etc Gentle skin care/handling What is topical treatment for skin tears? - ✔✔Type 1: cleanse, roll viable flap back and secure with steristrips Type 2 and 3: cleanse with saline, dress with silicone adhesive foam, silicone contact layer + wrap gauze, solid glycerine gel dressing (low exudate), nonadherent gauze with wrap gauze, nonadherent polyurethane foam with wrap gauze What is MARSI? - ✔✔Medical adhesive related skin injury Erythema or other skin damage that persists 30 minutes plus after adhesive removal How do you prevent MARSI? - ✔✔Avoid products that cause reaction Consider liquid barrier films Apply to dry skin without tension Low and slow horizontal removal - support skin adjacent to peel line Paper and silicone tapes are better
What special considerations exist for paper tape, acrylate adhesive? - ✔✔must be applied with firm pressure and adhesion increases over time What is IAD? - ✔✔Incontinence associated dermatitis External moisture - begins with inflammation and moves to skin loss How do you prevent IAD? - ✔✔Toileting programs, containment devices, absorptive products with polymers to wick away from skin What types of moisture barrier products exist? - ✔✔Petrolatum products Dimethicone products Zinc oxide Alcohol free liquid barrier films Why/when do you use petrolatum moisture barrier products? - ✔✔easy to apply and remove thin layer to avoid transfer to brief/pad because it will interfere with absorption Not adherent or protective with denudation or liquid stool Why/when do you use dimethicone moisture barrier products? - ✔✔easy to apply/remove non-occlusive - good for diaphoresis+incontinence inadequate for denudation/liquid stool
How do you manage periwound MASD? - ✔✔appropriate dressings Moisture barriers where adhesion is not a problem What causes peristomal MASD? - ✔✔exposure to effluent and perspiration How do you prevent peristomal MASD? - ✔✔secure pouching system correctly size pouch protection of peristomal skin appropriate pouch change frequency How do you manage peristomal MASD? - ✔✔treat denuded areas with pectin powder + alcohol free liquid barrier or hydrocolloid/foam dressing under patch What causes pressure injuries? - ✔✔prolonged/intense pressure shear force reduced/compromised tissue tolerance Why does prolonged/intense pressure cause pressure injuries? - ✔✔ischemia from occluded capillaries, edema and waste buildup from occluded lymph capillaries, reperfusion injury from thrombi formed during stasis, oxygen free radicals that damage vessel endothelial lining
Why does shear force cause pressure injuries? - ✔✔friction + gravity, angulation and disruption of blood vessels, irregular deep lesions What types of reduced/compromised tissue tolerance contribute to pressure injuries? - ✔✔muscle wasting loss of subq tissue underlying vascular disease/edema/hypotension hyperthermia smoking stress ________ pressure means _________ time tolerance - ✔✔reduced increased What do redistribution surfaces do? - ✔✔reduce intensity of pressure What does routine repositioning do? - ✔✔reduces time factor restores blood and lymphatic flow and interstitial fluid to compromised area What do conformable surfaces do? - ✔✔Minimize interstitial fluid shifts and minimize degree of capillary and lymph occlusion How do you reduce shear? - ✔✔Limit HOB elevation
How do you manage deep tissue injuries? - ✔✔pressure redistribution and reduction of shear no debridement until clear necrotic tissue What are the braden scale score categories? - ✔✔9 or below - very high risk 10 - 12 high risk 13 - 14 moderate risk 15 - 18 at risk What braden scale scores must you address? - ✔✔Any 2 or below What are the braden scale categories? - ✔✔Sensory perception Moisture Activity Mobility Nutrition Friction and Shear How do you rank in the braden scale category sensory perception? - ✔✔ 1 - limited ability to feel pain over most of body 2 - limits ability to feel pain over 1/2 of body 3 - limits ability to feel pain in 1-2 extremities 4 - no impairment
How do you rank in the braden scale category moisture? - ✔✔ 1 - consistently moist - detected every time pt moved or turned 2 - skin often but not always moist - linens must be changed once a shift 3 - occasionally moist - extra linen change once a day 4 - rarely moist How do you rank in the braden scale category activity? - ✔✔ 1 - bedfast 2 - chairfast 3 - walks occasionally for short distances with or without assistance 4 - walks frequently at least twice a day How do you rank in the braden scale category mobility? - ✔✔ 1 - completely immobile - no changes in position 2 - Very limited - occasional slight changes 3 - frequent through slight changes 4 - major and frequent changes in position How do you rank in the braden scale category nutrition? - ✔✔ 1 - NPO or clear liquids for more than 5 days; never eats a complete meal, rarely eats more than 1/2 of food offered 2 - generally eats 1/2 of food offered, receives less than optimum amt of tube feeding 3 - eats over half of most meals or gets most nutritional needs from TPN 4 - eats most of every meal, eats between meals, never refuses meal
How deep must air chambers be for alternating pressure surfaces? - ✔✔Air chambers must be at least 10cm in depth What is air fluidized therapy? - ✔✔Surfaces that involve a tank filled wiht siliconized glass beads that create a fluid medium when air is forced through the beads Provides very high level immersion and envelopment as well as high level air flow What are the issues with air fluidized therapy? - ✔✔difficult to get patient out of bed and difficult to maintain head elevation Not for cardio/respiratory issues or tube feedings What is low air loss? - ✔✔low flow of air against the patient's skin designed to control skin heat and humidity What is support surface active therapy? - ✔✔powered surface with air chambers that are alternately inflated and deflated according to defined cycle and not in response to patient's weight What is support surface reactive therapy? - ✔✔surfaces that react to patient's weight by creating comfortable surface (foam, gel, water bed, air, sheepskin) no change in pressure points What are the phases of partial thickness wound repair? - ✔✔1. inflammatory response
- epithelial cell proliferation and migration
- reestablishment of normal skin layers and skin thickness What happens in the partial thickness inflammatory response? - ✔✔24 hours erythema, edema, serous exudate What happens in the epithelial cell proliferation and migration phase of partial thickness wound healing? - ✔✔may begin within 8 hours Needs attachment of keratinocytes to wound bed and stimulation by growth factors How do you promote epithelial cell proliferation? - ✔✔Clean, moist, healthy wound bed Low bacterial counts normal Blood glucose normal amount of growth factors and MMPs What occurs in epithelial cell proliferation and migration stage if there is dermal loss? - ✔✔ 5 days post-injury a layer of fluid separates epidermis from dermis Blood vessels sprout Collagen synthesis begins day 9 to 15 and extends into fluid layer, new epidermis collapses around new vessels and collagen to form rete ridges What happens in the reestablishment of normal skin layers and skin thickness phase of partial thickness skin repair? - ✔✔when migrating epithelial cells make contact, migration ceases Cells resume upward migration and differentiation
