Term
True or false, normal pH of skin is alkaline |
|
Definition
F, The pH of normal healthy skin is slightly acid not alkaline
|
|
|
Term
True or False
Dermis is normally acid and dry |
|
Definition
| F, Dermis is the innermost layer of skin that is naturally moist and slightly acid . |
|
|
Term
True or False
Epidermis can regenerate |
|
Definition
| T, Epidermis is the outer layer of skin, composed of the stratified squanous epithelial cells, which can reproduce/ regenerate to replace lost cells. |
|
|
Term
True or False
Subcutaneous tissue is the 3rd layer of the skin |
|
Definition
| F, subcutaneous tissue is not a layer of skin. Only the epidermis and dermis comprise the skin. Subcutaneous tissue is fatty tissue/adipose underneath the skin that provides putting a protection. |
|
|
Term
True or false
Muscle tissue is more susceptible to pressure injury then skin. |
|
Definition
| T, muscle tissue is highly vascular with a higher metabolic rate and therefore is more susceptible than skin to effects of prolonged pressure. Muscle is also not capable of reproduction/ regeneration |
|
|
Term
| Identify anatomical differences that increase the risk of skin tears on newborns in the elderly |
|
Definition
| Rene pegs and rete ridges are epidermal growth protrusions that project down into the dermis to interlocked with the dermal papillae to provide strength and stability of the skin layers and prevent skin tears. Without the interlocking of the epidermis to the dermis, or if there is flattening of this junction, the epidermis can easily be torn away from the dermis. Does interlocking feature has not yet found in the newborn, and is lost in the elderly; this resultsk in reduced cohesion between the |
|
|
Term
True or False
Pressure applied to the skin causes the greatest amount of pressure at the epidermis. |
|
Definition
| F, Pressure extends from the surface in a pressure gradient with the highest pressure at the Boen/tissue interface rather than at the skin surface. Pressure usually results in full thickness Damage. |
|
|
Term
True or False
Partial thickness (Superficial) breakdown can be caused by friction or maceration. |
|
Definition
| T, superficial partial thickness skin ulcers are loss of epidermis and possible partial loss of dermis. The damage occurs from top down in superficial injuries. Over hydrated skin is more susceptible to injury and friction where the top layers of skin cancer or upgraded from excess rubbing of skin (such as elbows/ heels) on / or against external surfaces. |
|
|
Term
True or False
Pressure ulcers/Injuries are caused by ischemia. |
|
Definition
| T, Tissues need intermittent blood flow. Compression of tissue between a bone and external surface/cast/splint or device, compresses blood vessels and can cut off the blood flow to tissue resulting in ischemia that causes tissue damage and, if prolonged, ulceration. |
|
|
Term
True or False
Maceration toughens the skin. |
|
Definition
| F, Maceration causes cellular edema, which makes the cell more vulnerable to breakdown. Healthy skin is "cool and dry"; macerated skin is "at risk". |
|
|
Term
| Name 2 preventive interventions for skin tears? |
|
Definition
| For patients with or at risk for skin tears, caution should by used with their skin at all times to avoid injury and damage. Aggressive, adhesive products/tapes/dressings should be avoided when at all possible, Dressings can be secured with roller gauze or wraps instead of tapes. If taping cannot be avoided, skin sealants or protective dressings can be placed on the skin prior to application of the tape to prevent stripping of the skin on removal. Patients' skin should be treated/handled gently at all times to prevent injury. Emollients should be routinely applied to help keep skin supple to resist injury. Protective sleeves, garments or clothes can provide a protective layer over the skin to prevent injury. Staff should use lift sheets or lift products for transfers and avoid grasping patients by their limbs. |
|
|
Term
Which of the following represents appropriate goals for topical management of a skin tear with total flap loss?
A. Debridement necrotic tissue; treatment infection; management exudate.
B. Establishment open wound edges; maintenance moist wound surface; prevention
infection
C. Avoidance further trauma; absorption exudate; maintenance moist wound surface
D. Wicking of tunnels; prevention infection; creation dry wound surface |
|
Definition
6. Goals are to prevent additional damage - thus dressings with aggressive adhesives
must be avoided. In addition, it is important to absorb any exudate since chronic
wound fluid impairs the repair process, and to maintain a moist wound surface, in
order to maintain cell viability and promote cell migration. There are a number of
dressing protocols that can be used to implement these key principles. |
|
|
Term
| 7. List at least two dressings that could be used appropriately for skin tear management |
|
Definition
7. Appropriate dressings for skin tears with partial or total flap loss would include:
--Gentle adhesive foam dressings: these dressings provide exudate control, a
moist wound surface, and atraumatic removal.
--Nonadhesive foam dressings secured with wrap gauze: this combination would
also provide exudate control, a moist wound surface, and atraumatic removal.
Nonadherent contact layer (e.g., adaptic, petrolatum gauze, silicone adhesive
contact layer) covered with dry gauze and secured with wrap gauze. Again, this
would provide exudate control, a moist wound surface, and atraumatic removal. |
|
|
Term
| 8. List 2 primary factors that cause full-thickness skin breakdown: |
|
Definition
8. Pressure and shear are the two primary factors resulting in full-thickness skin
breakdown, such as pressure injury. Pressure damage occurs over bony prominences
or under medical devices where tissue and vessels are compressed causing ischemia.
Such full thickness damage begins at the bottom and progresses upward. There are
multiple contributing factors that weaken the tissue’s tolerance to the effects of
pressure/shear and increase the susceptibility for the skin breakdown such as edema,
hypotension, tobacco use, stress, fever, loss of subcutaneous tissue/muscle wasting,
previous ulcers, etc |
|
|
Term
9. Which of the following processes is most likely to cause undermining and/or tunneling of
pressure ulcers/injuries?
A. Shearing
B. Friction
C. Incontinence
D. Maceration |
|
Definition
9. A Undermining or tunneling is tissue destruction under the skin that occurs in
pressure ulcers/injuries believed to be due to shear forces when skin slides—skin goes
one way and underlying tissues/skeleton go the opposite direction. For example,
shearing occurs when a patient slides down in a bed or a chair and the tissue layers
slide against each other causing kinking and tearing of blood vessels and tissue.
Friction, incontinence and maceration are associated with partial thickness injury
rather than full thickness injury such as undermining/tunneling. |
|
|
Term
10. Indicate whether each of the following is most likely to be associated with ITD, IAD, or
pressure ulceration/injury (PU/I):
___ located at base of body fold (natal cleft)
WTA Review Questions: Lesson 2
WTA Program: wta@wocn.org
2
___ located over bony prominence
___ patient requires absorptive products due to fecal and urinary incontinence
___ patient is obese and diaphoretic
___ skin damage located in perineal area |
|
Definition
10. ITD, PU/I, IAD, ITD, IAD
The most important factors in differential assessment of trunk wounds is location,
wound characteristics, and factors to which the patient has been exposed.
-IAD is located in the perineal area, is typically superficial, and occurs only in
individuals with urinary and fecal incontinence.
-ITD is located at the base of body folds or on opposing surfaces of body folds, is
typically superficial and frequently linear, and occurs in individuals who are
diaphoretic. It is common in the obese population.
-Pressure ulcers/injuries (PU/I) occur over bony prominences or under medical
devices, are frequently deep, and occurs in individuals with very limited mobility. |
|
|
Term
1. According to the Braden Risk Scale, match the following scores to the level of risk:
16 ___ A. Low risk
8 ___ B. Moderate risk
12 ___ C. High risk
14 ___ D. Very high risk |
|
Definition
1. The Braden Score is an inverse measure of risk; i.e., the higher the risk, the lower the score.
Barbara Braden recommends the following categories of risk:
15 – 18: Relatively low risk but preventive care indicated
13 – 14: Moderate risk
10 – 12: High risk
<10: Very high risk |
|
|
Term
2. Name 3 interventions to prevent shear and friction:
1)
2)
3) |
|
Definition
2. Friction damage is superficial abrasive damage caused by the skin rubbing against the linens,
chair cushion, mattress, etc; shear damage is typically deep damage caused by “sliding force”,
which occurs when the tissue layers slide against each other, resulting in compression or
disruption of the blood vessels. Shear damage is most likely to occur when the head of the
bed is elevated and the patient slides down in bed; in this situation, the superficial layers tend
to “stick to the sheets” and the deep layers slide down in response to gravity. Measures to
minimize friction and shear damage include the following: gentle skin care and handling; use
of support surfaces with low-shear low-friction covers; use of lift sheets for repositioning;
limiting head of bed elevation; use of knee gatch when head of bed elevated; use of
protective dressings over surfaces exposed to friction and shear (e.g., use of silicone adhesive
foam dressings over sacrococcygeal area of high-risk patients); use of wheelchair/chair
cushion to maintain correct position and prevent sliding |
|
|
Term
3. Which of the following are recommended to prevent pressure ulcer/injury? Check all that
apply
___ Massage red skin over bony prominences
___ Turn every 2 hours if bedbound
___ Keep head of bed at 90 degrees
___ Use 30 degree lateral positioning for side-lying
___ Sheepskin under heels
___ Elevate heels off surfaces
___ Hourly weight shifts if chairbound
___ Eggcrate mattress |
|
Definition
3. --Massage is NOT recommended for reddened skin over bony prominences as this can cause
mechanical damage to at-risk skin. In the past, massage was recommended, because it was
thought to cause vasodilatation and increased blood flow; we now realize that skin redness
means the vessels in the area are already dilated (in response to some degree of cellular
damage)
--Keeping the head of the bed elevated to 90o
increases the risk of shear damage over the
sacrococcygeal area and also increases the amount of pressure exerted against the sacrococcygeal
tissues. To minimize the risk of pressure injury, the head of the bed should be kept
at < 30°.
--To provide protection against pressure ulcer/injury development, the heels must be kept
OFF the bed. Sheepskin is NOT a pressure relieving device.
--Hourly weight shifts ARE recommended for at risk-patients who are up in the chair,
because the sitting position results in high interface pressures over the ischial tuberosities
(and possibly the coccyx).
--Frequent turning and repositioning is a key preventive intervention for bedbound patients,
WTA Review Questions and Answers: Lesson 3
WTA Program: wta@wocn.org
3
because turnig and repositioning offloads the tissues and restores blood flow. The currently
recommended interval for turning and repositioning is Q 2 – 4 hours, with the specific
frequency for a specific patient determined by his or her overall risk and the type of support
surface on which he/she is positioned.
--The 30o
side-lying position is the currently recommended angle, because the goal of the
side-lying position is to effectively offload the sacrococcygeal area while avoiding
positioning directly onto the trochanter.
--Heel elevation is the currently recommended approach to protection of the heels because
currently there is no support surface that adequately redistributes pressures over the heel
tissues and the underlying calcaneous bone.
--An eggcrate mattress does NOT provide sufficient pressure redistribution to be used as a
therapeutic support surface. |
|
|
Term
4. Which of the following patients is at risk for nutritional compromise?
A. Patient with recent unplanned weight loss
B. Prealbumin level of 22
C. Recent weight gain of 5 lbs
D. NPO for 24 hours |
|
Definition
4. A Recent unplanned weight loss is indicative of a catabolic state, which must be corrected
before healing can occur. Prealbumin levels < 10 are usually considered indicative of
significant nutritional compromise; however, prealbumin levels are affected by a number of
systemic factors and cannot be used as a “stand alone” indicator of nutritional status. Recent
weight gain suggests either fluid accumulation or an anabolic state, neither of which are
indicative of nutritional compromise. NPO status for a limited period of time (such as 24
hours) does not impact nutritional status. |
|
|
Term
5. Indicate whether the following patients need a midlevel (ML) or a highlevel (HL) therapeutic
support surface?
___ Skin intact, moderate risk ___ 1 ulcer on sacrum, moderate risk
___ Ulcer on right and left trochanter ___ Skin intact, high risk
___ Cannot be turned due to pain ___ Ulcers on coccyx, sacrum and right trochanter |
|
Definition
5. --Patient who is at moderate risk and has no breakdown: needs mid-level pressure
redistribution and has a number of turning surfaces that can be used and that can withstand
periods of reduced blood flow. MID-LEVEL surface.
--Patient who has ulcers on right and left trochanters: needs high-level pressure
redistribution because he/she will require repositioning on areas of breakdown and your goal
is to minimize interference to blood flow and interference to wound healing. HIGH-LEVEL
surface.
--Patient who cannot be turned due to pain: needs high-level pressure redistribution to
minimize the interference to blood flow and therefore reduce the risk of breakdown. HIGHLEVEL
surface.
--Patient with breakdown on sacrum, at moderate risk: needs mid-level pressure
redistribution because he/she has two intact surfaces and therefore can be placed on a side to
side positioning program that protects the trochanters and maintains constant blood flow to
the sacrum. MID-LEVEL surface.
--Patient with intact skin who is high risk: needs high-level pressure redistribution and
protection against shear and friction and against moisture. HIGH-LEVEL surface.
WTA Review Questions and Answers: Lesson 3
WTA Program: wta@wocn.org
4
--Patient with ulcers on coccyx, sacrum, and right trochanter: needs high-level pressure
redistribution to minimize interference to blood flow and promote healing when patient is
positioned in supine or right side-lying position (because patient has only one intact surface). |
|
|
Term
True or False
6. ___ Heel protectors and heel elevation devices can be used interchangeably |
|
Definition
6. F Heel protectors provide variable protection against friction and shear but do NOT protect
against pressure; heel elevation devices protect against all forms of mechanical trauma
(friction, shear, and pressure). Therefore, heel elevation devices are the standard of care, and
can NOT be used interchangeably with heel protectors. |
|
|
Term
True or False
7. ___ Patients on high-level turning surfaces do not require turning or repositioning |
|
Definition
7. F All patients require turning and/or repositioning at routine intervals, unless there is a
medical contraindication for turning and repositioning. Routine turning and repositioning is
beneficial not only for maintenance of tissue viability but also for the health of other body
systems, such as the lungs. |
|
|
Term
True Or False
8. ___ All immobile patients require heel elevation, even if they are on high-level surfaces. |
|
Definition
8. T As noted, the heel bone (calcaneous) is a large bone with very little overlying soft tissue;
therefore, simple redistribution of the pressure does not provide adequate protection. Heel
elevation is the current standard of care for all at-risk patients. |
|
|
Term
True/false:
1. ___ Charting by exception is a good approach to documentation of preventive care. |
|
Definition
1. F Charting by exception is NOT a good approach to documentation of preventive care,
because it provides no proof that preventive care was provided. |
|
|
Term
True or False
2. ___ Either narrative or flow sheet charting of preventive care is acceptable. |
|
Definition
2. T Either narrative or flow chart documentation of preventive care is acceptable, because
either approach provides evidence that care was provided. |
|
|
Term
True or False
3. ___ Documentation of pressure ulcers/injuries "present on admission" can be done at any
point during the lst 72 hours of hospitalization. |
|
Definition
3. F Documentation of ulcers/injuries “present on admission” must be included in the
admission assessment; if not documented at the time of admission, the ulcer/injury must be
considered to be hospital-acquired. (MD verification of ulcer/injury presence on admission
and ulcer/injury stage can be completed at any time during the admission.) |
|
|
Term
4. List two components of a comprehensive pressure ulcer/injury prevention program that must
be completed at the time of admission.
1)
2) |
|
Definition
4. List two assessments/interventions that are part of a comprehensive pressure ulcer/injury
prevention program and that must be completed at the time of admission.
1) Skin assessment/documentation of any breakdown present on admission.
2) Pressure ulcer/injury risk assessment.
3) Implementation of a prevention protocol for any patient found to have breakdown at
the time of admission and for any patient found to be at risk for pressure ulcer/injury
development at the time of admission. |
|
|
Term
True/false:
1. ___ Full-thickness wounds heal by regeneration |
|
Definition
1. F Full thickness wounds extend past the skin layers into the subcutaneous tissue and may
involve muscle and bone; these layers are unable to regenerate. Thus full thickness wounds
are forced to heal via connective tissue repair (scar formation); the primary phases of full
thickness repair include inflammation, proliferation, and maturation. |
|
|
Term
True/false:
2. ___ Blood clotting interferes with initial wound healing |
|
Definition
2. F Blood clotting does not interfere with the initial phases of wound healing; clotting
involves degranulation of platelets, which results in the release of growth factors. Growth
factors attract the cells needed for repair, and play a powerful role in promoting wound
healing. |
|
|
Term
True/false:
3. ___ A mature wound scar is stronger than the pre-wounded skin |
|
Definition
3. F A mature wound scar is at best only 80% as strong as the original tissue; thus wounds
that heal by scar formation are always more vulnerable to repeat breakdown. |
|
|
Term
4. The correct sequence of events in repair of a chronic full-thickness wound is:
__________________________________ |
|
Definition
4. The correct sequence of events in repair of a chronic full-thickness wound is: inflammation;
proliferation; and maturation. Inflammation establishes a clean wound bed via elimination
of necrotic tissue and control of bacterial loads; proliferation involves formation of
granulation tissue to fill the defect, contraction of the wound edges to reduce the size of the
defect, and epithelial resurfacing to establish an intact bacterial barrier. Maturation involves
development of tensile strength and establishment of a strong thin scar. |
|
|
Term
5. The presence of _______________ or _______________ in a wound will result in prolonged
inflammation. |
|
Definition
5. The presence of infection or necrotic tissue in a wound will result in prolonged
inflammation. The goal of the inflammatory phase is to establish a clean wound bed that
supports granulation tissue formation. Thus infection and necrosis prolong the inflammatory
phase, because it takes longer to establish a clean wound bed in the presence of necrosis or
infection. |
|
|
Term
6. In an acute wound healing by primary intention, absence of a healing ridge by days _______
to _______ indicates increased risk of dehiscence. |
|
Definition
6. In an acute wound healing by primary intention, absence of a healing ridge by days 5 to 9
indicates increased risk of dehiscence. Normally granulation tissue formation begins by day
4 to 5 postop and can be detected as a palpable ridge extending 1 mm on either side of the
incision. If there is no healing ridge, it indicates a delay in granulation tissue formation, and
a delay in granulation tissue formation increases the risk of incisional separation/dehiscence. |
|
|
Term
7. The presence of granular red tissue in the wound bed suggests the wound is in what phase of
repair?
A. Hemostasis
B. Inflammation
C. Proliferation
D. Maturation |
|
Definition
7. C Presence of granular red tissue is indicative of granulation tissue formation, which is the
key event in the proliferative (rebuilding) phase of wound repair. Hemostasis is the initial
phase of repair and is relevant only to acute wounds (incisions or lacerations); the
WTA Review Question Answers: Lesson 5
WTA Program: wta@wocn.org
2
inflammatory phase is characterized by presence of necrotic tissue or heavy bacterial loads;
and maturation is characterized by a closed wound. |
|
|
Term
8. In managing a partial thickness wound, which of the following is/are known to be critical to
repair?
A. Maintenance of clean dry wound surface
B. Routine administration of oxygen by nasal cannula
C. Tight glucose control
D. High dose zinc throughout repair process |
|
Definition
8. C Hyperglycemia is a known impediment to all phases of healing; thus tight glucose control
is a critical element of wound management. The wound surface should be kept clean and
moist, as opposed to clean and dry; there is currently no evidence that routine administration
of oxygen via nasal cannula enhances the repair process; and high dose zinc is
contraindicated as it interferes with copper absorption, and copper is essential to repair. |
|
|
Term
True or False
1. ___ All patients with full thickness wounds should receive zinc and high doses of vitamin C |
|
Definition
1. F There is no evidence that routine administration of zinc and vitamin C has a positive
impact on wound healing. Routine administration of zinc is actually contraindicated; zinc
should be given only on a short-term basis and only when the patient is known or thought to
be zinc deficient. Vitamin C is important to wound repair but routine administration of
supplemental vitamin C is usually NOT needed since vitamin C is present in a wide variety
of foods and fluids (so most patients have no trouble getting in sufficient amounts). |
|
|
Term
True or False
2. ___ Unplanned weight loss of 5% in 6 months indicates nutritional compromise |
|
Definition
2. F Unplanned weight loss of 5% of body weight in 6 months does not necessarily indicate
nutritional compromise. (Involuntary weight loss of > 10% of usual weight in 6 months or
> 5% in 30 days is an important indicator of compromised nutritional status, and ongoing
weight loss is indicative of a catabolic state.) |
|
|
Term
True or False:
3. ___ Protein is necessary for collagen synthesis in wound healing |
|
Definition
3. T Collagen is a connective tissue protein, and protein is required for both collagen synthesis
and maintenance of immune system function. |
|
|
Term
4. Which of the following systemic factors impede wound healing? Check all that apply.
A. Presence of eschar
B. Use of tobacco
C. Blood sugar of 100
D. Edema |
|
Definition
4. B and D. Tobacco use interferes with healing because it causes vasoconstriction and impairs
tissue oxygenation; perfusion and oxygenation are essential to repair. Edema interferes with
healing because it creates a barrier to oxygen diffusion into the tissues. Eschar does interfere
with healing but it is a local factor as opposed to a systemic factor. A blood sugar of 100
represents normoglycemia, which promotes wound healing. |
|
|
Term
5. ________________________ partially counteracts the negative effects of steroids on wound
healing. |
|
Definition
5. Topical vitamin A partially counteracts the negative effects of steroids on wound healing.
Steroids interfere with wound healing by preventing migration of white blood cells into the
wound bed; vitamin A encourages the migration of white blood cells into the wound bed.
Therefore topical vitamin A can be applied to the base of clean wounds to help counteract the
negative effect of steroids. |
|
|
Term
6. What are the calorie and protein requirements for a patient who weighs 154 lbs and has a
chronic wound?
Calories:
Protein: |
|
Definition
6. Caloric requirements: 2100 – 2450 calories/day
Protein requirements: 87.5 – 105 gm protein/day
Calculations: Convert weight in lbs to weight in kg (154 ÷ 2.2 = 70.0 kg)
Caloric requirements: wt in kg x 30 – 35. 70 x 30 = 2100 calories. 70 x 35 = 2450 calories.
Protein requirements: wt in kg x 1.25 – 1.5. 70.0 x 1.25 = 87.5 gm protein; 70.0 x 1.5 = 105 gm
protein. |
|
|
Term
True/False:
1. ___ A serum filled blister is a Stage I pressure ulcer/injury. |
|
Definition
| 1. F A serum filled blister is a Stage II pressure ulcer/injury. |
|
|
Term
True/False:
2. ___ Stage IV pressure ulcers/injuries are full-thickness ulcers with extensive destruction,
tissue necrosis, or damage to muscles, bone, or supporting structures. |
|
Definition
2. T Stage IV is the highest level of pressure ulcer/injury stage. Stage IV ulcers extend
through the skin, fascia, and subcutaneous tissue, into the muscle, tendon, joint
capsule, cartilage, or bone. Depth of a Stage IV ulcer can vary according to the
anatomical location. |
|
|
Term
True/False:
3. ___ Blanching refers to whiteness when pressure is applied to a reddened area. |
|
Definition
3. T If significant inflammation or injury is not present, intact skin will blanch or turn
white when pressure is applied to reddened skin over a bony prominence. Darkly
pigmented skin may not show visible blanching, but its color may vary from the
surrounding skin. |
|
|
Term
True/False:
4. ___ Stage I pressure ulcers/injuries have intact skin. |
|
Definition
4. T Non-blanchable erythema of a localized area of intact skin over a bony
prominence indicates a Stage I pressure injury. |
|
|
Term
True/False:
5. ___ Stage III pressure ulcers/injuries involve full-thickness skin loss. |
|
Definition
5. T Stage III pressure ulcers/injuries extend through the epidermis, dermis and into
the subcutaneous tissue but bone, tendon, or muscle are not exposed. The depth of a
Stage III ulcer can vary according to the anatomical location. |
|
|
Term
True/False:
6. ___ Stage II pressure ulcers/injuries involve loss of the epidermis and may involve partial
loss of
the dermis. |
|
Definition
6. T Stage II pressure ulcers/injuries are a partial loss of dermis presenting as a
shallow open ulcer with a pink wound bed without slough or bruising. A Stage II
ulcer/injury may also present as a serum filled blister. |
|
|
Term
True/False:
7. ___ An area of deep purple intact skin over a bony is classified as DTI. |
|
Definition
7. T Deep tissue injury (DTI) presents as a purple, or maroon, localized area of
discolored intact skin or a blood-filled blister due to damage of the underlying soft
tissue from pressure and/or shear. The initial depth is unknown. DTI may be difficult
to detect in persons with dark skin tones. Evolution of the injury may be rapid
exposing additional layers of tissue, even with optimal treatment. Evolution may
include a thin blister over a dark wound bed. |
|
|
Term
True/False:
8. ___ Reverse staging is innapropriate according to the NPUAP (National Pressure Ulcer
Advisory Panel) and WOCN Society (Wound, Ostomy and Continence Nurses Society). |
|
Definition
8. T Staging is based on identifying the anatomic tissue layers that are damaged. The
staging system does not reflect the pathology of the pressure ulcer/injury
development, but only the depth of tissue damage. Reverse staging a healing wound
is not clinically or physiologically accurate, because deeper tissues heal by connective
tissue repair (i.e., development new blood vessels and connective tissue proteins) and
do not regenerate or reproduce the lost tissue. |
|
|
Term
True/False:
9. ___ Stage IV pressure ulcers/injuries cannot heal to Stage III or II pressure ulcers/injuries. |
|
Definition
9. T Stage IV pressure ulcers/injuries, as full-thickness wounds, do not reverse heal to
Stage III or II because of the healing process that repairs the wound with granulation
tissue formation/connective tissue repair (i.e., development new blood vessels and
WTA Review Question Answers: Lesson 7
WTA Program: wta@wocn.org
2
connective tissue proteins). Once the wound is determined to be a Stage IV, it
remains a Stage IV. It can be classified as a non-granulating, granulating, partially
granulating, fully granulated or healed Stage IV. Stage III ulcers/injuries are also fullthickness
wounds and cannot be reverse staged as they do not heal to Stage II, etc. |
|
|
Term
True/False:
10. ___ A pressure ulcer/injury covered with eschar or necrotic tissue is a Stage III pressure
ulcer/injury. |
|
Definition
10. F A pressure ulcer/injury covered with eschar, slough, or necrotic tissue cannot be
staged accurately. After the necrotic tissue is debrided sufficiently to expose the
wound base, the pressure ulcer/injury can be staged based on tissue layers that are
visible. |
|
|
Term
True/False:
11. ___ Undermining is tissue destruction that occurs under intact skin. |
|
Definition
11. T Tissue destruction can cause undermining of intact skin resulting in dead space in
a wound and can be a source of abscess formation. Undermining involves a large
portion of the wound edge and presents as a large space or cavity under the skin (e.g.,
undermining from 3 o’clock to 9 o’clock extending 3 cm from wound edge). In
contrast, sinus tracts (tunnels) are narrow and involve only a small amount of the
wound edge; however, they may be quite long/deep (e.g., tunnel at 12 o’clock
extending 7 cm from wound edge). |
|
|
Term
True/False:
12. ___ All red wounds are healthy. |
|
Definition
12. F All red wounds are not healthy. Healthy granulation tissue is beefy red and moist
with a cobblestone or berry-like appearance. However, red tissue can also present as
“hypergranulation tissue” which is excess tissue that prevents healing.
Hypergranulation extrudes up higher than the wound margins, bleeds very easily
(friable) and must be removed for the wound to heal. Also, hypergranulation tissue
that recurs repetitively, despite proper treatment, can be a sign of cancerous tissue.
Extremely friable red tissue can also be a sign of critical colonization. |
|
|
Term
True/False:
13. ___ Healing can be determined by accurate assessment of wound status. |
|
Definition
13. T Complete, thorough and accurate assessment of wound status on a regular basis is
key to determining healing or lack of progress toward healing. Current findings
should be compared to previous findings and evaluated in light of the healing
potential and expected outcomes and objectives for the patient. |
|
|
Term
True/False:
14. ___ Tunneling is defined as a sinus tract that usually connects 2 wounds. |
|
Definition
14. F Long, narrow tunnels/tracts can occur from tissue destruction under intact skin in
a wound but the tunnels/tracts do not necessarily connect 2 separate wounds: finding
a connection is possible but not typical. |
|
|
Term
True/False:
15. ___ Depth of narrow tunnels can be measured by a small polethylene catheter. |
|
Definition
15. T In some cases tunnels/tracts are so narrow that the depth cannot be measured
using an ordinary cotton tipped applicator. To measure depth in a very narrow tunnel,
a safe approach is to gently insert a small caliber catheter (e.g., 8-12 Fr, disposable
catheter) with a smooth blunt end to avoid trauma. |
|
|
Term
| 16. What unit of measurement is used to record wound measurements (length, width, depth)? |
|
Definition
16. Size of wounds should not be estimated. Specific measurements (i.e., length, width,
depth) should be taken using measuring devices and recorded in centimeters. |
|
|
Term
| 17. What is the recommended frequency for assessing/measuring wounds? |
|
Definition
17. It is recommended that a comprehensive assessment of wounds be conducted at least
weekly with documentation of the findings. Assessment provides the foundation to
judge healing and assess wound status. Assessment is the basis for making treatment
decisions about modifications in topical therapy and making referrals for additional
evaluation or adjunctive therapies. |
|
|
Term
18. What is the name for closed, non-proliferative wound edges, where the top layers of
epidermis have rolled over and down, and which are associated with non-healing wounds? |
|
Definition
18. The wound edge should be assessed to determine if the wound edge or rim is open or
closed/non-proliferative, such as occurs with epibole. Epibole occurs when the top
layer of epidermis rolls down and covers the lower edge of the epidermis, preventing
epidermal migration. Epibole is often removed by application of silver nitrate to the
epidermal edge (with a physician’s order) or by a physician’s surgical excision. |
|
|
Term
19. Name 3 methods for measuring length and width and describe how they differ in
determining length and width: |
|
Definition
19. Three methods have been used for measuring a wound’s length and width. Each
method differs in determining the location for measuring length and width. The
“clock” method uses the face of a clock to orient for taking the measurements with
the patient’s head at the 12 o’clock position. In the clock method, the length is
measured at the 12-6 o’clock position and the width from 9-3 o’clock. The “greatest
length and width” method measures the longest length and width across the wound
irrespective of any orientation to a clock face or location of the patient’s head. The
“greatest length and width, head to toe” method, measures the greatest length on the
wound in a head to toe orientation and the greatest width side to side, perpendicular to
the length. The key point in measuring wounds is using a consistent method with the
same approach and with the patient in the same position. |
|
|
Term
20. Of the 3 different methods for measuring length and width of wounds, identified in question
number 19, which is the current recommended method? |
|
Definition
20. The greatest length and width “head to toe” method is the current recommended
approach for measuring length and width and has been adopted for use on the OASIS
(Outcome and Assessment Information Set) for home care; the Minimum Data Set
used in long-term care facilities, and by the National Pressure Ulcer Advisory Panel
in their Pressure Ulcer Scale for Healing (PUSH Tool). |
|
|
Term
21. What does a red raised area (i.e., erythema and induration) extending 4 cm around a wound
indicate? |
|
Definition
| 21. Erythema/induration greater than 2 centimeters around a wound indicates cellulitis. |
|
|
Term
| 22. Within how many weeks should wounds healing in a timely manner show signs of progress? |
|
Definition
22. Wounds that are progressing toward healing should show signs of progress in 2
weeks. Failure of the wound to show progress for 2 consecutive weeks, despite proper
therapy indicates a need for re-evaluation of the patient and need to modify the
treatment plan |
|
|
Term
23. What is the stage of a pressure ulcer/injury over the trochanter that is partially covered with
yellow slough and has exposed muscle?
A. Deep tissue injury
B. Unstageable
C. Stage III
D. Stage IV |
|
Definition
23. D If muscle is exposed in the wound over the trochanter, it is staged as a Stage IV.
In this case, the yellow tissue is only partially covering the wound allowing
visualization of the muscle. Because the muscle is observable, it can be accurately
staged. Muscle would not be visible in a deep tissue injury, in an unstageable pressure
ulcer/injury, or in a Stage III pressure ulcer/injury. |
|
|
Term
1. Before beginning a wound treatment plan, it is critical to determine the treatment goal. List 3
types of goals. |
|
Definition
Comfort, maintenance, and healing.
A comfort goal is appropriate for patients at end of life.
A maintenance goal is appropriate when healing is very unlikely due to inability to correct
causative factors or inability to provide systemic support. When the goal is maintenance the
focus is on prevention of infection and other complications.
When causative factors can be corrected and systemic support can be provided, the goal
should be healing. |
|
|
Term
| 2. Dakin’s solution is inactivated by exposure to _____________ and _________________. |
|
Definition
2. Dakin’s solution is inactivated by exposure to heat and light.
Dakin’s solution is a very dilute bleach solution, and bleach is inactivated by heat and light.
Dakin’s solution must either be stored in an opaque container in a cool environment, or must
be replaced Q 24 – 48 hours. |
|
|
Term
3. When using an enzyme to debride thick dry eschar, it is critical to first _______________ the
eschar. |
|
Definition
3. When using an enzyme to debride thick dry eschar, it is critical to first crosshatch the eschar.
This is because enzymatic preparations require a moist environment for effectiveness;
crosshatching creates “grooves” in the eschar that allow the enzymatic agent to penetrate to a
moist tissue layer. |
|
|
Term
| 4. List two strategies for reduction of pain related to dressing changes. |
|
Definition
4. Strategies for reduction of pain related to dressing changes:
Premedicate the patient. Use topical anesthetic agents prior to painful procedures; Use
nonadherent dressings; Use gentle techniques for wound care; Allow the patient to call
“time out”.
Premedication blocks pain signals at the CNS level; topical anesthetic agents block pain
signals at the wound bed; nonadherent dressings and gentle technique reduce nociceptive
stimuli that cause pain; allowing the patient to call “time out” provides the patient with
control and reduces anxiety, which helps to reduce pain. |
|
|
Term
| 5. List two solutions that can be used for cleansing both clean and dirty wounds. |
|
Definition
5. Solutions that can be used for cleansing either clean or dirty wounds: saline, tap water, or
commercial wound cleanser. These solutions are noncytotoxic and therefore nondamaging
to clean wounds but can be used with high pressure irrigation to mechanically remove loose
debris, bacteria, and exudate from the surface of dirty wounds. |
|
|
Term
6. Enzymatic debridement is enhanced by application of a _________-thick layer and
maintenance of a ______________ environment. |
|
Definition
6. Enzymatic debridement is enhanced by application of a nickel-thick layer and maintenance
of a moist environment.
A nickel thick layer of the ointment is required for 24 hours of enzymatic activity, and the
enzyme is active only in a moist environment. |
|
|
Term
| 7. List two signs of critical colonization: |
|
Definition
7. Two signs of critical colonization: sudden deterioration in quantity or quality of
granulation tissue, or sudden plateau in wound healing progress; recurrent formation
slimy “film” on wound surface; increased pain; increased exudate.
Critical colonization involves heavy bacterial loads on the wound surface that interfere with
fibroblast activity and granulation tissue formation. Determination of critical colonization is
a clinical diagnosis – there is no diagnostic tool at present. Since the definition of critical
colonization is “bacterial loads heavy enough to interfere with wound healing”, the clinical
indicators are poor quality granulation tissue, reduced production of granulation tissue,
sudden plateau in wound progress or sudden deterioration, and indicators of high bacterial
loads, such as increased exudate and increased pain. Prompt detection of critical
colonization requires comparison of wound status at present to wound status at last
evaluation point. |
|
|
Term
True/false:
8. ___ Eschar is a protective dressing for the wound and serves to promote healing. |
|
Definition
8. F Eschar delays wound healing because the wound cannot move into the proliferative phase
until the wound bed is clean and free of necrotic tissue. Eschar is sometimes considered
protective (e.g., when an ischemic uninfected leg ulcer is covered with dry adherent eschar
the eschar serves as a bacterial barrier). Thus in a maintenance situation the eschar would be
left in place and the wound would be monitored for evidence of infection. However,
whenever the goal is healing the eschar must be removed. |
|
|
Term
True or False
9. ___ Whirlpool is the preferred method of cleansing for wounds in the proliferative phase. |
|
Definition
9. F Clean granulating wounds should be cleansed with gentle flushing or “blotting”;
high pressure irrigation and whirlpool are contraindicated since these approaches to cleansing
would disrupt structures at the wound surface that are contributing to repair, such as
fibroblasts. |
|
|
Term
True or False
10. ___ Dilute Dakin’s solution is an appropriate debridement option for wounds that are
necrotic, infected, and malodorous. |
|
Definition
10. T Dilute Dakin’s solution effectively dissolves necrotic tissue, kills almost all bacteria
associated with chronic wounds, and eliminates odor. |
|
|
Term
True or False
11. ___ Conservative sharp wound debridement is within the scope of practice for all wound
care clinicians. |
|
Definition
11. F Conservative sharp debridement is within the scope of practice for MDs, midlevel
providers (NPs and PAs), and PTs; it is also within the scope of practice for specialty wound
care nurses in most states. Wound care nurses should check with the Board of Nursing in
their state to determine whether or not CSWD is in their scope of practice. CSWD is NOT
within the scope of practice for LPNs. |
|
|
Term
True or False
12. ___ When obtaining a swab culture, it is critical to completely saturate the culturette tip
with purulent wound fluid (pus). |
|
Definition
12. F When obtaining a swab wound culture, it is critical to flush the wound bed thoroughly
and to swab 1 square cm of viable tissue with enough force to produce exudate. Necrotic
tissue and purulent fluid should not be cultured, because the goal is to isolate the bacteria
invading the viable tissue. |
|
|
Term
True or False
13. ___ Silver dressings should be used in conjunction with enzymatic debriders to prevent
secondary wound infection |
|
Definition
13. F Silver dressings are contraindicated for use in conjunction with enzymatic debriders,
because the silver ions inactivate the enzyme. |
|
|
Term
True or False
14. ___ Wet to dry dressings are the gold standard for management of necrotic wounds. |
|
Definition
14. F Wet to dry dressings are a non-selective form of debridement; removal of the dried gauze
frequently causes damage to the viable tissue, bleeding, and pain. Wet to dry dressings are
no longer recommended. |
|
|
Term
True or False
15. ___ Debridement is contraindicated in an ischemic noninfected wound with dry eschar |
|
Definition
15. T The goal in management of a necrotic uninfected ischemic wound is maintenance; in this
situation, adherent eschar maintains a closed wound and provides a bacterial barrier.
Debridement would create an open wound with very limited potential for healing. |
|
|
Term
True or False
16. ___ Contaminated wounds will not heal until the bacteria are eliminated. |
|
Definition
16. F Low levels of bacteria do not interfere with healing; contamination is defined as the
presence of non-replicating bacteria that are not interfering with healing, and no treatment is
required. |
|
|
Term
True or False
17. ___ Tunneled and undermined areas must be tightly packed to prevent abscess formation. |
|
Definition
17. F Tight packing of undermined and tunneled areas is contraindicated because it would
prevent closure and would impair perfusion. The goal in managing tunnels and undermined
areas is to “wick” (evacuate) fluid, thus preventing abscess formation, and to prevent
premature closure of narrow tunnels, without interfering with the wound repair process. |
|
|
Term
True or False
18. ___ Cauterization with silver nitrate is appropriate treatment for hypertrophic granulation
tissue and closed wound edges. |
|
Definition
18. T Silver nitrate cauterization removes the unhealthy top layer of hypertrophic granulation
tissue and reduces bacterial counts; silver nitrate cauterization can also be used to remove the
occluding skin layers and to reestablish open wound edges. |
|
|
Term
19. Which of the following wounds SHOULD be debrided?
A. Dehisced abdominal incision that is just beginning to granulate
B. Trochanteric pressure ulcer/injury that is 80% necrotic
C. Heel wound covered with dry eschar; no signs of infection
D. Ischemic foot ulcer covered with eschar; no signs of infection |
|
Definition
19. B A trochanteric pressure ulcer/injury that is 80% necrotic must be debrided in order to
move the wound through the inflammatory phase and into the proliferative phase.
A granulating wound has no necrotic tissue and does not need debridement.
A heel wound covered with dry eschar and with no signs of infection should NOT be
debrided until the patient has been assessed to determine that there is adequate
perfusion to support healing and that healing is feasible.
Debridement is contraindicated for an ischemic foot ulcer covered with eschar and
with no signs of infection; the goal in this case is maintenance/prevention of infection
and the eschar is helping to maintain a closed wound and to prevent infection. |
|
|
Term
20. A wound culture is indicated for which of the following?
A. Any wound that fails to heal within 4 weeks
B. Any wound with necrotic tissue
C. Foot wound in a diabetic patient
D. Wound associated with signs of cellulitis |
|
Definition
20. D A wound culture is indicated for a wound with signs of invasive infection (cellulitis); the
culture will identify the infecting organism and will also provide critical information
regarding effective antibiotics. The culture and sensitivity is done to direct treatment.
Wound culture is NOT indicated just because a wound has not healed within 4 weeks;
failure to close is not necessarily due to infection.
Culture is not indicated just because the wound has necrotic tissue; necrosis may be
associated with infection but is not routinely associated with infection. Culture should be
limited to wounds with signs of infection.
Foot wounds in diabetic patients may or may not be associated with infection. Culture
is indicated only for wounds associated with signs of infection. |
|
|
Term
21. Which of the following is the recommended approach for cleansing a wound that is 100%
granulating?
A. Irrigation with 35 cc syringe and 19 gauge angiocath
B. Whirlpool or pulsed lavage using saline
C. Gentle flushing with saline
D. Commercial wound cleanser delivered with 8 – 15 psi irrigation force |
|
Definition
21. C. Clean granulating wounds should be cleansed gently with a noncytotoxic solution such
as saline, to avoid disruption or damage to the viable cells and newly synthesized connective
tissue proteins on the wound surface.
Forceful irrigation is contraindicated with clean granulating wounds due to the potential for
damage or disruption of the viable cells and newly synthesized connective tissue at the
wound surface.
Whirlpool and pulsed lavage are contraindicated with clean granulating wounds due
to the potential for damage or disruption of the viable cells and newly synthesized connective
tissue at the wound surface.
Commercial cleanser delivered with 8 – 15 psi irrigation force is contraindicated due to
the potential for damage or disruption of the viable cells and newly synthesized connective
tissue at the wound surface. |
|
|
Term
22. Which of the following is the most appropriate intervention for a wound that shows evidence
of critical colonization?
A. Wound culture followed by treatment with systemic antibiotics
B. 1-week course of dry dressings
WTA Review Questions: Lesson 9
WTA Program: wta@wocn.org
3
C. Daily whirlpool x 1 week
D. Sustained release antimicrobial dressing |
|
Definition
22. D Critical colonization by definition reflects high bacterial loads at the wound surface;
since the infection is limited to the wound surface, treatment should be focused at the wound
surface. Sustained release antimicrobial dressings exert their antibacterial effects at the
wound surface, and are an excellent choice because they are very broad-spectrum.
Wound culture and systemic antibiotics are indicated for wounds with signs of invasive
infection (cellulitis), but not for wounds with infection limited to the wound surface.
Wounds with infection limited to the wound surface should be treated topically and do not
require systemic treatment.
A 1-week course of dry dressings would not be effective for a wound with critical
colonization (would not eliminate bacterial loads) and would be damaging to the viable cells
(such as the WBCs) within the wound bed.
There is no evidence that daily whirlpool for a week would eliminate heavy bacterial loads at
the wound surface. |
|
|
Term
23. Your patient has a wound over the right ischium that has been present for 6 months, has high
volume exudate, and tunnels to the bone. Which of the following is the most appropriate
response?
A. Referral to Physical Therapy for whirlpool twice daily
B. Suggest a 1-week trial of Dakin’s soaked gauze
C. Suggest antimicrobial dressing to the tunnel
D. Request MD consult to rule out osteomyelitis |
|
Definition
23. D. A nonhealing tunnel is one possible sign of osteomyelitis, and requires evaluation to
WTA Review Question Answers: Lesson 9
WTA Program: wta@wocn.org
5
either establish or “rule out” this diagnosis.
Osteomyelitis requires treatment with antibiotics; twice daily whirlpool would be of no
benefit.
Dakin’s soaked gauze provides control of bacterial at the wound surface, but would be of no
benefit in treatment/management of osteomyelitis.
Antimicrobial dressings reduce bacterial loads at the wound surface, but would be of no
benefit in treatment/management of osteomyelitis. |
|
|
Term
24. Which of the following dressings would be most effective in promoting autolysis for a
wound with thick dry eschar?
A. Silver based foam
B. Hydrogel
C. Wet to dry gauze
D. Calcium alginate dressing |
|
Definition
24. B Autolytic debridement requires establishment/maintenance of a moist wound surface,
which promotes WBC migration. It is the WBCs that are the active agent in autolytic
debridement (i.e., it is the WBCs that break down the necrotic tissue).
Silver based foam would not provide autolysis for a wound with dry eschar, because
autolysis requires a moist wound surface and foam dressings ABSORB any moisture. Foam
dressings are totally contraindicated for dry wounds since all phases of repair require a moist
wound surface.
Wet to dry gauze is no longer recommended for debridement because it is non-selective. In
addition, application of wet gauze that is allowed to dry in contact with the wound surface
does NOT provide for autolysis – autolysis occurs only in a moist wound environment,
because autolysis is dependent on WBC migration, which requires a moist wound surface.
Calcium alginate dressings cannot be used for debridement of dry eschar, because alginate
dressings are dry dressings that work to absorb exudate, and autolysis requires a moist wound
surface. |
|
|
Term
25. Select the most appropriate debridement option for each of the following:
Infected wound:
A. autolytic debridement
B. chemical debridement (dilute Dakin’s soaked gauze)
Large amount of necrotic tissue involving bone/joint:
A. surgical
B. enzymatic
Wound with thin layer of adherent slough:
A. conservative sharp
B. enzymatic
Adherent dry eschar in patient with clotting abnormalities:
A. autolytic
B. conservative sharp
Large amount loose slough:
A. conservative sharp
B. enzymatic |
|
Definition
25. Infected wound: chemical debridement is more appropriate because it provides for bacterial
control as well as debridement.
Necrotic wound involving bone/joint: surgical debridement is more appropriate because it
is faster and permits exploration of the wound (and bone resection/biopsy if indicated) in a
sterile environment.
Thin layer adherent slough: enzymatic debridement is more appropriate because it is safe;
sharp debridement carries significant risk of bleeding when there is a thin layer of adherent
avascular tissue.
Adherent eschar in patient with clotting abnormalities: autolytic debridement is more
appropriate because instrumental debridement of adherent eschar carries significant risk for
bleeding, which could be prolonged and excessive in a patient with clotting abnormalities.
WTA Review Question Answers: Lesson 9
WTA Program: wta@wocn.org
6
Large amount loose slough: conservative sharp debridement is more appropriate because
it is fast and safe for removal of loose slough. |
|
|
Term
| 26. List the 8 principles of topical therapy: |
|
Definition
26. Principles of topical therapy:
Debride necrotic tissue
Identify and treat infection
Wick tunnels and undermined area
Absorb excess exudate
Maintain moist wound surface
Open wound edges
Protect healing wound from trauma and infection; protect periwound skin from
maceration and MARSI
Insulate healing wound
Debridement of necrotic tissue and treatment of infection is necessary to move the wound out
of the inflammatory phase and into the proliferative phase.
Wicking fluid from tunnels is necessary to prevent infection/abscess formation and to prevent
premature closure of narrow tunnels.
Absorption of excess exudate is necessary to eliminate inflammatory substances that would
interfere with wound healing.
A moist wound surface is needed to maintain cell viability and to promote cell migration.
Open wound edges are necessary for epithelial resurfacing to occur.
The healing wound needs protection from trauma and from bacterial invasion, either of
which would compromise the repair process. Periwound skin must be protected against
maceration and medical adhesive related skin injury, which would result in extension of the
wound.
Insulation is necessary to optimize cellular activity. |
|
|
Term
| 1. List at least 4 functions of dressings. |
|
Definition
1. Dressing functions include the following:
i. Wicking fluid from tunnels and undermined areas (to prevent trapped fluid that could
result in abscess formation)
ii. Absorption of exudate (wound exudate contains high levels of inflammatory substances
and bacteria, both of which can be detrimental to wound healing; thus it is important to
minimize contact between the wound surface and the wound exudate)
iii. Maintain a moist wound surface (a moist wound surface maintains viability of the cells in
the wound bed and promotes cell migration, thus facilitating repair)
iv. Provision of a bacterial barrier for wounds exposed to stool and urine (contamination
with stool and/or urine increases the risk of infection and delays healing)
v. Provision of atraumatic removal. Traumatic removal of wound dressings removes newly
formed tissues and delays healing; traumatic removal may also cause extension of the
original wound.
vi. Insulation. Dressings that provide some degree of insulation (by reducing heat loss from
the wound surface and/or by reducing frequency of dressing change) enhance wound
healing, because cellular activity is greatest when wound bed temperature is close to body
temperature. |
|
|
Term
2. Identify factors to be considered in: a.) selection of a contact (primary) dressing; and
b.) selection of a cover (secondary) dressing. |
|
Definition
2. Selection of the dressing in direct contact with the wound bed (primary dressing) is based on
wound depth and contours (i.e., presence of tunneled or undermined areas) and on volume of
exudate; for example, a wound with depth or tunnels requires a dressing that fits into the
wound and conforms to the wound surface (filler dressing), whereas a surface wound can be
managed with a flat dressing. Similarly, a wet wound needs an absorptive dressing, whereas
a dry wound requires a dressing that donates and/or traps moisture to create a moist wound
surface.
Selection of the cover (secondary) dressing is based on the volume of exudate and exposure
to urine or stool. For example, the cover dressing for an abdominal wound with minimal
exudate should be designed to maintain moisture within the wound bed, and would not need
to provide a bacterial barrier. In contrast, the cover dressing for a sacral wound in an
incontinent patient would need to be waterproof in order to provide protection against
bacterial invasion. |
|
|
Term
3. Explain why occlusive dressings such as hydrocolloids are considered contraindicated
for use with infected wounds |
|
Definition
3. Infected wounds require more frequent dressing changes (both for cleansing and removal of
bacterial breakdown products and for wound assessment), and typically require highly
absorptive dressings since infection produces increased volumes of exudate. Hydrocolloid
dressings are designed for 3 – 5 day wear times and can absorb only small amounts of
exudate so would not be appropriate for these wounds. In addition, occlusive dressings
WTA Review Question Answers: Lesson 10
WTA Program: wta@wocn.org
2
prevent diffusion of atmospheric oxygen into the wound bed and this could increase the risk
of anaerobic infection, especially in wounds that are poorly perfused. Finally, we lack data
proving that occlusive dressings can be safely used for infected wounds. |
|
|
Term
4. Explain the significance of each of the following in dressing selection:
wound depth; tunneled or undermined areas; volume of exudate; exposure to stool or urine |
|
Definition
4. Wounds with depth require a conforming filler dressing, as do wounds with tunneled or
undermined areas; very narrow tunnels require a wicking type dressing that can be safely
removed (e.g., a nonwoven gauze or fabric “ribbon” dressing). In contrast, wounds with no
depth, no tunnels, and no undermined areas require only a flat “cover” type dressing.
Exudate. Wet wounds require absorptive dressings to manage the exudate while maintaining
a moist surface, whereas wounds with minimal exudate require a dressing that traps moisture
(to maintain a moist wound surface) and totally dry wounds require a dressing that donates
moisture (to create a moist wound surface.)
Wounds exposed to stool and/or urine require a waterproof cover dressing that provides a
bacterial barrier. |
|
|
Term
| 5. List one option for protection of the skin around an exudative wound: |
|
Definition
5. One option for protection of the skin around an exudative wound: liquid barrier film;
moisture barrier ointment; hydrocolloid dressing. The goal is to “waterproof” the skin,
and the specific product chosen is dependent primarily on the location of the wound. If the
wound is located on the trunk, a liquid barrier film or hydrocolloid dressing is usually the
best option since trunk wounds typically require adhesive dressings, and use of a moisture
barrier ointment would interfere with adhesion. In contrast, dressings on extremity wounds
are commonly secured with wrap gauze; in this situation a moisture barrier ointment would
be a very appropriate choice for periwound skin protection. |
|
|
Term
6. ___ An alginate rope is the BEST option for wicking fluid from a very narrow tunnel
(0.2 cm in diameter) |
|
Definition
6. In wicking a very narrow tunnel, the goals are to effectively evacuate the fluid from the
tunnel and to use dressing material that can be effectively removed with no retained fibers
that could cause a foreign body reaction. An alginate rope is NOT a good option for a
narrow tunnel because there is significant risk for leaving retained fibers. |
|
|
Term
7. Which of the following is MOST accurate in regards to gauze dressings?
A. Nonwoven gauze is preferred in situations where the gauze is in direct contact with
the wound bed.
B. Wet to dry dressings are the “gold standard” for most wounds
C. Gauze dressings are contraindicated for use in open wounds
D. Woven gauze is preferred to nonwoven gauze because it promotes exudates transfer |
|
Definition
7. A Nonwoven gauze is the preferred option for gauze in contact with the wound bed,
because nonwoven gauze is not associated with loose fibers that act as foreign bodies and is
less likely to adhere to the wound bed and to cause trauma with removal.
Wet to dry dressings are applied wet, allowed to dry, and then removed; wet to dry dressings
are associated with significant trauma to the wound bed and are now considered
contraindicated.
Gauze dressings are not totally contraindicated for use in open wounds; gauze is the
appropriate delivery system for antiseptics such as Dakin’s solution. The goal is to select
gauze dressings that do not cause adverse events.
WTA Review Question Answers: Lesson 10
WTA Program: wta@wocn.org
3
Nonwoven gauze is preferred to woven gauze; nonwoven gauze is less likely to adhere to the
wound surface and does not have loose fibers that can act as foreign bodies. |
|
|
Term
8. Which of the following is the BEST management plan for a dehisced abdominal wound
measuring 8 cm x 4 cm x 3 cm with minimal exudate?
A. Hydrocolloid dressing
B. Alginate rope + adhesive foam dressing
C. Silver based hydrofiber + dry gauze + transparent adhesive dressing
D. Liquid hydrogel layer + damp gauze + transparent adhesive dressing |
|
Definition
8. D A dehisced abdominal wound with depth and minimal exudate falls into the category of
“deep and dry”. Deep dry wounds need a hydrating filler dressing and cover dressing. A
layer of hydrogel + damp gauze would protect and hydrate the wound surface and a
transparent adhesive dressing would maintain hydration of the wound surface.
A hydrocolloid dressing is a cover dressing and therefore not appropriate as a solo dressing
for a wound with depth.
A transparent adhesive dressing is a cover dressing and therefore not appropriate as a solo
dressing for a wound with depth.
A hydrofiber and gauze filler dressing are absorptive dressings intended for deep wet
wounds and would be inappropriate for a wound with minimal exudate. |
|
|
Term
9. Your patient has a large skin tear on her right arm measuring 5 cm x 3 cm x 0.1 cm; there
is a large amount of serosanguinous exudate. Which of the following is MOST appropriate?
A. Hydrocolloid dressing
B. Transparent adhesive dressing
C. Nonadherent gauze (e.g. Adaptic) + dry gauze + wrap gauze
D. Liquid gel + dry gauze + wrap gauze |
|
Definition
9. C This wound would be classified as shallow and wet; a contact layer dressing + dry gauze
and wrap gauze would manage the exudate while maintaining a moist wound surface. This
dressing combination would also provide for atraumatic removal, which is important in a
patient with fragile skin.
A hydrocolloid dressing would not be appropriate because it cannot handle large volumes of
exudate and does not provide atraumatic removal.
A transparent adhesive dressing would not be appropriate because it provides no exudate
management and does not provide atraumatic removal.
Liquid gel is not needed for a wet wound, and the dry gauze could become adherent to the
wound bed. |
|
|
Term
10. Your patient has a trochanteric pressure ulcer/injury that measures 7 cm x 6.5 cm x 3 cm. There is
a large amount of drainage. Which of the following would be MOST appropriate?
A. Alginate dressing to line wound bed; dry fluffed gauze as filler; adhesive foam cover
B. Gel-soaked gauze to line wound; dry fluffed gauze as filler; transparent adhesive cover
C. Woven gauze moistened with saline as filler; gauze/tape cover
D. Highly absorbent silicone adhesive foam |
|
Definition
10. A This is a deep wet wound; alginate dressings provide exudate management and the dry
fluffed gauze provides additional absorption, as does the foam cover dressing.
Gel soaked gauze is indicated for a deep dry wound because it provides hydration; it is not
appropriate for a wet wound.
Woven gauze is not recommended as a primary contact layer dressing because it tends to
stick to the wound bed and is likely to “shed” loose fibers into the wound.
An adhesive foam dressing is not an appropriate stand alone dressing for a wound with depth
because it is a cover dressing. |
|
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Term
True/False:
1. ___ Wounds that fail to heal within 4 weeks should be considered refractory. |
|
Definition
1. F Wounds should be considered refractory if they fail to demonstrate measurable progress
for two consecutive weeks despite appropriate comprehensive management. Most chronic
wounds take many weeks or even months to heal completely, but a wound that is responding
appropriately to treatment should demonstrate steady progress in healing. |
|
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Term
True or False
2. ___ Active wound therapies provide active stimulation of the repair process. |
|
Definition
2. T Standard wound dressings provide passive support for wound healing, through exudate
management, maintenance of a moist wound surface, and protection against trauma and
bacterial invasion. Active wound therapies and products actively stimulate the repair process
by changing the levels of stimulating or inhibiting factors or activating intracellular processes
critical to repair. |
|
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Term
True or False
3. ___ Bioengineered skin equivalents and skin grafts should be applied only to clean
well-vascularized wounds. |
|
Definition
3. T Bioengineered skin substitutes and skin grafts provide a replacement epidermis for
shallow healthy wounds; the graft or skin substitute must be applied to a clean wellvascularized
wound bed for the following reasons: 1) Application to a wound with heavy
bacterial counts is associated with a very high failure rate (> 90%), whereas application to a
clean wound bed is associated with a very high success rate; and 2) Graft viability is initially
maintained by diffusion of oxygen and nutrients from the underlying wound bed into the
graft; once the vessels from the surrounding tissues “grow into” the skin substitute or graft,
the graft becomes self-sustaining, but this takes 4 – 7 days. |
|
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Term
True or False
4. ___ Wounds that fail to heal due to tissue hypoxia can be managed with either topical
oxygen therapy, oxygen by nasal cannula, or hyperbaric oxygen therapy. |
|
Definition
4. F Wounds that fail to heal due to tissue hypoxia should be evaluated for revascularization
and/or hyperbaric oxygen therapy; there is no evidence that topical oxygen therapy or oxygen
given by nasal cannula will be of benefit. Revascularization improves oxygen levels by
restoring blood flow to the wound bed, and hyperbaric oxygen improves tissue oxygenation
by increasing the levels of oxygen dissolved in the plasma. |
|
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Term
True or False
5. ___ Hyperbaric oxygen therapy is the treatment of choice for a dry necrotic toe. |
|
Definition
5. F Hyperbaric oxygen is of no benefit in the management of a dry necrotic toe because it
cannot restore perfusion; it is appropriate for wounds with viable but hypoxic tissue that will
benefit from increased plasma oxygen levels. |
|
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Term
True or False
6. ___ Collagen dressings promote repair by providing a scaffold for cell migration. |
|
Definition
6. T Collagen dressings promote healing of refractory wounds partially by providing a
scaffolding for cell migration. The cells involved in wound healing must be able to migrate
across the cell bed and attach to the wound bed before they can reproduce or carry out repair
activities such as collagen synthesis. In refractory wounds, the wound bed may not support
cell migration and attachment; collagen-based dressings can promote healing in these
wounds by providing an effective “scaffolding/framework” for migration and attachment |
|
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Term
True or False
7. ___ A 3” foam overlay is the surface of choice for a patient immediately following a
myocutaneous flap procedure. |
|
Definition
7. F Nursing care for patients who have undergone myocutaneous flap procedures must
include placement on an air support surface that provides high level pressure redistribution, a
low shear friction surface, and microclimate control (low volume air flow). A 3” foam
overlay would not provide sufficient pressure redistribution, would not protect against
friction and shear, and would not provide microclimate control. |
|
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Term
True or False
8. ___ Wound biopsy is appropriate for a nonhealing wound when the reason for failure to
heal is not clear. |
|
Definition
8. T Wound biopsy should always be performed when the reason for failure to heal is not
known, because chronic wounds can deteriorate into malignancies such as Marjolin’s ulcer
(squamous cell carcinoma). Wound biopsy can also help to identify other pathologic
conditions contributing to nonhealing, such as vasculitis. |
|
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Term
True or False
9. ___ Low levels of MMPs (matrix metalloproteases) are one reason for failure to heal. |
|
Definition
9. F High levels of MMPs are normal during the inflammatory phase, but MMP levels
decrease dramatically as wounds approach the proliferative phase. Persistent high levels of
MMPs are associated with chronic inflammation and failure to heal. |
|
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Term
| 10. List at least 4 contraindications to Negative Pressure Wound Therapy. |
|
Definition
10. List at least 4 contraindications to Negative Pressure Wound Therapy:
Wound with significant necrotic tissue. Negative Pressure Wound Therapy is designed
to promote granulation tissue formation so is most appropriate for wounds that are clean
but slow to granulate. There is no evidence that NPWT is of benefit in debridement of
necrotic wounds.
Osteomyelitis. Wounds will not heal if there is infected bone in the base of the wound; it
is essential to treat osteomyelitis before beginning negative pressure wound therapy as
the wound will be unable to benefit from the NPWT if there is infected bone.
Untreated infection. Infection causes prolongation of the inflammatory phase; the
wound cannot move into the proliferative phase (granulation tissue formation) until
bacterial loads have been controlled. Therefore infection should be treated before NPWT
is initiated, so that the wound is “ready” for NPWT (i.e., able to granulate).
Exposed organs or vessels. NPWT is not strictly contraindicated in these situations;
however, a contact layer or the dense white foam must be used over the wound base to
prevent ingrowth of tissue into the foam. Options for a contact layer include oil emulsion
dressing or silicone adhesive contact layer. If the white foam is used, the contact layer is
optional since the white foam is non-porous.
Malignant wounds. NPWT is designed to promote tissue growth, which is totally
contraindicated in the presence of a malignancy.
Wounds where goal is maintenance or comfort. In these situations, the wound is very
unlikely to heal and it would be a waste of health care dollars to use an active wound
therapy. |
|
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Term
| 11. List 3 beneficial effects of Negative Pressure Wound Therapy. |
|
Definition
11. List 3 beneficial effects of NPWT.
Reduced edema. The negative pressure reduces interstitial edema, which improves
tissue perfusion and wound healing. The reduction in edema is also a major benefit in
management of wounds at risk for compartment syndrome.
WTA Review Question Answers: Lesson 11
WTA Program: wta@wocn.org
3
Management of wound fluid. Chronic wound fluid contains large amounts of
inflammatory mediators and bacterial toxins; thus a key element of principle-based
wound care is effective management of wound fluid. NPWT effectively and consistently
suctions wound fluid away from the wound surface and thus protects the wound bed from
the negative effects of exposure to wound fluid.
Maintenance of moist wound surface. A moist wound surface is essential to
maintenance of cell viability and to promotion of cell migration, and NPWT maintains a
moist wound surface through use of transparent adhesive drape.
Macro and micro deformation. The negative pressure creates deformation of the cells
in the wound bed (i.e., the negative pressure changes the shape of the wound cells); this
activates intracellular processes that promote neoangiogenesis and collagen synthesis. |
|
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Term
12. The primary benefit of HBOT is which of the following?
A. Exposure of wound to air
B. Vasodilation of the arteries
C. Increased oxygen dissolved in the plasma
D. Increased hemoglobin |
|
Definition
12. C Hyperbaric oxygen therapy involves administration of oxygen to a patient who is in a
pressurized chamber or room, which results in increased levels of oxygen dissolved in the
plasma. The end result is increased tissue oxygenation and support for wound healing.
Hyperbaric oxygen does not involve exposure of the wound to air, and this would not be
therapeutic, since exposure to air would increase the risk of wound surface dehydration and
would not increase tissue oxygenation.
Hyperbaric oxygen actually helps to reduce vasodilatation; vasodilatation is a compensatory
response to chronic hypoxia and when tissues’ oxygen needs are met, the vessels return to
normal size (relative vasoconstriction). This is helpful since vasodilatation results in edema.
Hyperbaric oxygen has no effect on hemoglobin levels. |
|
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Term
13. The MD has ordered negative pressure wound therapy for your patient, but you are
concerned because there are exposed loops of bowel very close to the surface. Which of the
following modifications would be MOST appropriate in this situation?
A. Use intermittent suction
B. Use Granufoam Silver sponge
C. Obtain an order for a contact layer
D. Reduce the negative pressure to a maximum of 100mm Hg |
|
Definition
13. C Use of a contact layer is recommended by the manufacturer and by wound clinicians to
prevent ingrowth of tissue into the porous sponge, which could cause damage to exposed
organs or vessels. The recommended contact layers are oil emulsion dressing or a silicone
adhesive contact layer.
Intermittent suction would not provide protection against tissue adherence and organ/vessel
damage.
Use of the Granufoam Silver sponge would not provide protection against tissue adherence
and organ/vessel damage, because the Granufoam Silver is a porous sponge that increases
the risk for tissue adherence.
Reducing the negative pressure to no more than 100 mm Hg would not prevent tissue
adherence. |
|
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Term
14. The first priority in management of a non-healing pressure ulcer/injury is to:
A. Change the type and frequency of dressing changes
B. Refer the patient for a surgical flap
C. Change the type of support surface
D. Critically reevaluate the entire management plan |
|
Definition
14. D A wound may become non-healing either due to some deficit in the current management
plan or to some imbalance in regulatory factors at the cellular/molecular level. If the reason
for failure to heal is an imbalance in regulatory factors, the most appropriate management is a
shift to active wound therapy. If the reason for failure to heal is due to some deficiency in
the current management plan, a shift to active therapy would NOT be indicated until any
gaps in the management plan have been corrected. Thus the first step in management of a
refractory wound is a critical reevaluation of the entire management plan to assure that:
WTA Review Question Answers: Lesson 11
WTA Program: wta@wocn.org
4
etiologic factors have been identified and corrected; all systemic factors affecting repair have
been addressed; and topical therapy has been appropriate, has eliminated all necrotic tissue,
and has established control of bacterial loads and wound exudate.
Changing the type and frequency of dressing changes is indicated ONLY if dressings
currently in use are ineffective in managing wound exudate, controlling bacterial loads, and
maintaining a clean moist wound surface.
A surgical flap is indicated only for selected nonhealing wounds and would never be the first
priority in management.
Changing the type of support surface would be indicated only if the patient was on a surface
with limited pressure redistribution and could not be consistently positioned off of the ulcer. |
|
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Term
15. Which of the following is MOST CRITICAL to successful “take” of a bilayered skin
substitute such as Apligraf?
A. Prealbumin >15
B. Clean well vascularized wound bed
C. Daily dressing changes with thorough cleansing
D. Vitamin C supplementation |
|
Definition
15. B As explained, bilayered skin substitutes act as non-surgical skin grafts. There is strong
evidence that a clean wound bed is essential to “take”; high bacterial loads are associated
with an extremely high risk of graft failure. A well-vascularized wound bed is equally
important since the graft is initially nourished by the vasculature of the underlying wound
bed.
Prealbumin >15 is not essential, because successful “take” does not involve granulation
tissue formation. In addition, prealbumin levels are not a “standalone”indicator of nutritional
status.
Daily dressing changes with thorough cleansing is contraindicated for management of
bilayered skin substitutes – the newly applied skin substitute should be left undisturbed for at
least 7 days, as earlier dressing changes could actually disrupt the graft.
There is no evidence that vitamin C supplementation benefits healing or “take” of bilayered
skin substitutes. |
|
|
Term
16. In assessing a patient who is 1 day post myocutaneous flap procedure, you must constantly
assess the wound for evidence of:
A. Granulation tissue formation/palpable “healing ridge”
B. Epithelial resurfacing
C. Color, temperature, and presence or absence of edema
D. Critical colonization |
|
Definition
16. C The most common complications following myocutaneous flap procedures are vascular,
(i.e., ischemia and venous congestion), and prompt intervention is essential to prevent loss of
the flap. Indicators of ischemia due to embolus formation include coolness and cyanosis or
pallor of the flap. Indicators of venous congestion include warmth and edema.
Granulation tissue formation does not begin till about 4 days postop and there is no palpable
healing ridge until between 5 and 9 days postop.
Epithelial resurfacing is not complete until 2 – 3 days postop and is not the most critical
event in healing of the flap.
Critical colonization is unlikely to be an issue with a flap procedure since there is no open
wound. |
|
|
Term
True/False:
1. ___ Pedal pulse palpation is the most reliable indicator of lower extremity perfusion status. |
|
Definition
1. F Pedal pulses alone are not reliable to determine perfusion status. The dorsalis
pedis pulse is congenitally absent in 4-12% of the population and often while
palpating pulses, clinicians mistake feeling their own pulse for that of the patient’s. |
|
|
Term
True/False:
2. ___ Topical antibiotics are indicated to treat infected, necrotic arterial wounds. |
|
Definition
2. F Infected, necrotic arterial wounds should be treated with culture guided, systemic
antibiotics. |
|
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Term
| 3. What is the primary modifiable risk factor for lower extremity arterial disease (LEAD)? |
|
Definition
3. Smoking/tobacco use is the primary modifiable risk factor associated with lower
extremity arterial disease. Tobacco is associated with endothelial injury, lipid
accumulation and atherosclerosis. Nicotine is a powerful vasoconstrictor and
increases coagulability of the blood. |
|
|
Term
4. What is the type of pain that is characteristic of significant LEAD and is indicative of 50%
stenosis or occlusion? |
|
Definition
4. Intermittent claudication (IC) is the classic type of pain due to lower extremity
arterial disease caused by atherosclerosis. Intermittent claudication is defined as
reproducible pain in the calf, thigh or buttock that is brought on by activity, such as
walking, when the stenosed vessels cannot meet the tissue’s metabolic demand for
increased blood flow. IC is only relieved by approximately 10 minutes rest. IC is
often not recognized by patients or clinicians who mistake the pain for arthritis or
signs of normal “aging.” |
|
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Term
5. Identify the type of pain that is considered an ominous sign of occlusion and suggestive of
90% or greater stenosis/occlusion? |
|
Definition
5. As atherosclerosis in lower extremity arterial disease progresses, pain will occur with
less and less activity. As stenosis reaches about 90% or greater, pain can occur at
night (nocturnal pain) or rest. This is a more ominous sign of ischemia because pain is
occurring even without the metabolic demand of activity. Patients are often seen
dangling the affected limb off the bed or sleeping sitting up in a chair to try to relieve
the pain by keeping the limb in a dependent position. |
|
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Term
| 6. Name 2 adjunctive therapies for arterial ulcers. |
|
Definition
6. The first priority in managing arterial ulcers is improving perfusion status. Patients
who have viable but non-healing wounds should be evaluated for adjunctive
treatment with hyperbaric oxygen therapy (HBOT) that can be given with or without
revascularization. Transcutaneous oxygen measures can be taken to see if the tissues
are hypoxic and an oxygen challenge given to determine if there is a response to
HBOT. During HBOT, patients are given 100% oxygen under pressure, which
increases the oxygen dissolved in the plasma. HBOT enhances infection control and
collagen synthesis, which is necessary for healing. Another adjunctive therapy,
dynamic arterial flow augmentation (sequential or intermittent compression of the
limb), aids in effective drainage of the venous bed to decrease resistance and improve
arterial flow. In patients who are not candidates for revascularization, some studies
have shown improved blood flow, limb salvage and less pain in patients treated with
dynamic arterial flow augmentation. |
|
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Term
| 7. What must be determined before dry stable eschar on a lower extremity is debrided? |
|
Definition
7. Debridement is contraindicated in a closed, dry, uninfected wound on the lower
extremity, such as one covered with dry eschar, until blood flow has been evaluated
and determined to be adequate for infection control and healing. Debridement of a
dry, ischemic lesion removes the barrier to bacterial invasion and overwhelming
infection could precipitate limb loss. The dry ischemic lesion should be kept dry,
frequently assessed, and protected from pressure. If an ischemic limb becomes
infected and unstable, referral should be made for a vascular consult.
Revascularization and debridement are treatments of choice for limb salvage in an
infected, ischemic wound. |
|
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Term
8. What test has been recommended by several national guidelines to rule out LEAD in patients
with lower extremity wounds? |
|
Definition
8. Because pulse palpation and presence or absence of a history of claudication pain are
insufficient to confirm or rule out LEAD, the ankle brachial index (ABI) has been
recommended by several national guidelines to screen for LEAD in patients with
lower extremity wounds. The ABI is highly sensitive (95%) and specific (95%)
compared to arteriographically proven LEAD. Blood pressure values are taken in
both arms and ankles. The ABI is a ratio of ankle to arm blood pressure. If blood flow
is normal, the pressure at the ankle should equal or be slightly higher than that in the
arm with an ABI equal to or greater than 1.00. |
|
|
Term
9. How do cause, presentation and effects of LEAD differ in patients with diabetes compared to
those without diabetes? |
|
Definition
9. Diabetes mellitus (DM) is a significant risk factor for LEAD. Diabetes is associated
with increased plaque formation, blood viscosity, and hypercoagulability.
Hyperinsulinemia in type II diabetes may affect the vascular smooth muscle.
Compared to patients without diabetes, in patients with DM, LEAD is more extensive
and more likely to result in limb loss. In patients with DM, LEAD occurs
earlier/younger, is more likely to be bilateral and multisegmented, and affects the
lower leg most often. |
|
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Term
| 10. Name 3 lower extremity skin changes characteristic of LEAD. |
|
Definition
10. Due to poor perfusion, signs of chronic tissue ischemia on the skin of the lower
extremity include hair loss, ridged nails, thin shiny skin, pale or dusky color of the
skin, skin that is cool to touch, and skin that becomes pale or cyanotic when the limb
is elevated and has rubor (red-purple color) when dependent. Note: Some of the
changes such as hair loss and thin skin can also be due to aging, and thick, ridged
nails can be due to fungal infections. |
|
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Term
| 11. What is considered an abnormal capillary refill time? __ |
|
Definition
11. The time needed for the capillary bed to refill after it is occluded with pressure gives
some indication of circulatory status, and a delay of greater than 3 seconds may
indicate LEAD. However, capillary refill is not as valid as venous refill because
capillary refill can be affected by environmental factors such as temperature and other
factors. Therefore, capillary refill should be used to only confirm or support a clinical
judgement and should not be used as a sole indicator of perfusion status. |
|
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Term
| 12. What is considered an abnormal venous refill time? |
|
Definition
12. A prolonged venous filling time indicates LEAD. Venous refill is prolonged if it takes
longer than 20 seconds for the veins to refill after the leg is raised until the veins
WTA Review Question Answers: Lesson 12
WTA Program: wta@wocn.org
3
collapse, and then the leg is lowered to a dependent position. With LEAD, the
underlying slow perfusion from the arterial flow affects the time for the veins to refill. |
|
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Term
| 13. List 3 signs of infection in an ischemic wound. |
|
Definition
13. Infection is a common complication, but it is not always obvious in arterial/ischemic
wounds. Clinical signs of infection are often muted and subtle due to the diminished
blood flow. A faint halo of erythema may be all that is visible around an infected
wound. Other signs can be fluctuance, localized swelling, increased necrosis, or
increased pain or tenderness. |
|
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Term
14. Calculate the right and left ankle brachial index (ABI) for a patient with the following
systolic blood pressure values:
Right arm brachial: 160 mmHg; Left arm brachial: 150 mmHg
Right dorsalis pedis: 170 mmHg; Left dorsalis pedis: 100 mmHg
Right posterior tibial: 180 mmHg; Left posterior tibial: 80 mmHg
R ABI = _____/_____ = _____ L ABI = _____/_____ = _____ |
|
Definition
14. The ABI is calculated by dividing the higher of either the dorsalis pedis (DP) or
posterior tibial (PT) pressure for each leg by the higher of the right or left brachial
(arm) pressure. The brachial systolic pressure is considered the best noninvasive
indicator of mean arterial pressure, and because brachial pressures can also be
affected by arterial disease in the upper extremities, the higher of the systolic
pressures in either arm is used to calculate the ABI for both legs. Using the highest of
the ankle pressures (DP or PT) for each leg has been shown to provide the best
overall accuracy for detecting LEAD.
ABI = Higher of the dorsalis pedis or posterior tibial pressure
Higher of the right or left brachial pressure
Right ABI: 180 / 160 = 1.13
Left ABI: 100 / 160 = 0.63 |
|
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Term
15. In which of the following cases is a toe brachial index or toe pressure indicated?
A. ABI 0.50
B. ABI 0.90
C. ABI 1.10
D. ABI 1.40 |
|
Definition
Left ABI: 100 / 160 = 0.63
15. D A toe brachial index (TBI) or toe pressure is indicated if the ABI is greater than
1.30. The ABI can be elevated due to rigid/ poorly compressible ankle arteries due to
arterial stiffness and calcification that occurs in some patients with diabetes, renal
failure, or rheumatoid arthritis. Because the toe arteries are not typically calcified as
often or as early as ankle arteries, toe pressures/toe brachial index are recommended
to check the lower limb perfusion if the ABI is greater than 1.30 or the ABI is
unmeasurable due to noncompressible ankle arteries (i.e., unable to obliterate the
pulse signal at cuff pressure > 250 mmHg). Toe pressures are commonly measured in
vascular labs using small digit cuffs and photoplethysmography.
An ABI of 0.50 is a valid measure that indicates severe ischemia and warrants referral
for possible revascularization. An ABI value of 0.90 is a valid value indicating the
onset of LEAD; blood flow should be sufficient for healing and would not warrant
further testing at this time. An ABI of 1.10 is within a valid, normal range and does
not warrant further testing. |
|
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Term
| 1. Name 4 risk factors for lower extremity venous disease (LEVD): |
|
Definition
1. There are many risk factors for LEVD such as deep vein thrombosis (DVT), obesity,
multiple pregnancies or pregnancies that occur close together, prolonged standing,
sedentary life style, intravenous drug use, aging, loss of calf muscle function,
thrombophilia, and genetic predisposition. Some factors such as obesity, pregnancy,
thrombophlebitis, and thrombophilic conditions are risks for valve dysfunction.
Factors such as prolonged standing, sedentary lifestyle, or advancing age contribute
to muscle dysfunction. |
|
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Term
| 2. Identify 2 pathologic changes thought to contribute to the etiology of LEVD: |
|
Definition
2. The calf muscle pump and one-way valves normally work together to propel venous
blood toward the heart. The pathology of LEVD results primarily from failure of the
muscle pump and valve damage. Normal venous return is supported by calf muscle
contraction (e.g., during walking), which compresses the deep veins and propels
blood forward toward the heart. Without ambulation or in cases of muscle damage,
this function is impaired. Ordinarily, valves in the veins control the one-way venous
flow from the superficial to the deep veins. However, if the valves become damaged
and incompetent from such conditions as DVT and are unable to close, backflow of
blood occurs from the deep venous system to the superficial venous system causing
congestion, dilation of the capillaries, and increased pressures in the capillaries,
which leads to ambulatory venous hypertension. As congestion develops in the
venous system, fluid, serum proteins, and white blood cells (WBCs) leak into the
tissues causing fibrosis, inflammatory changes, and edema. Tissues are then
vulnerable to breakdown and ulceration. |
|
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Term
| 3. What is the hallmark sign of LEVD? |
|
Definition
| 3. Edema from the ankle to the knee is the hallmark sign of LEVD. |
|
|
Term
4. What is the name of the condition with induration and thickening of the skin that is
characteristic of LEVD? |
|
Definition
4. Lipodermatosclerosis is characterized by a thickened, indurated “leather like”
appearance of the skin on the lower legs, particularly around the ankle areas
(sock/gaiter areas); it can occur with longstanding LEVD. Lipodermatosclerosis
results from hardening and sclerosis of the fat and dermal tissues. |
|
|
Term
| 5. What causes the greyish, brown hyperpigmentation of the skin in patients with LEVD? |
|
Definition
5. Hemosiderosis is commonly seen on the skin of the lower legs/ankle areas as LEVD
progresses. Hemosiderin staining is a greyish, brown hyperpigmentation of the skin
that occurs from leakage of red blood cells and breakdown of hemoglobin in the
tissues. |
|
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Term
| 6. Where is the typical location for an ulcer due to LEVD to occur? |
|
Definition
6. The most common location for ulcers due to LEVD to occur is at or around the
medial malleolus of the ankle area (gaiter/sock area). If the ulcers are extensive they
can progress, involve larger areas, and occur circumferentially around the ankle and
lower leg. |
|
|
Term
| 7. What are common causes of dermatitis in patients with LEVD and how is it treated? |
|
Definition
7. Dermatitis is an inflammatory condition of the skin that is fairly common in patients
with LEVD. It occurs as a contact reaction to sensitizers/additives in topical products
such as lanolin in moisturizers or as a reaction to some topical antibiotics such as
neomycin. Dermatitis is often confused with cellulitis and treated with topical
antimicrobials that can exacerbate the condition. Because it is due to an inflammatory
reaction, key treatments are application of a topical steroid and avoidance of
sensitizing topical products. Typically, treatment with a topical steroid for about 2
weeks is sufficient to resolve the dermatitis, but if the symptoms are not controlled by
2 weeks, or they worsen, the patient should be referred to a dermatologist to evaluate
the need for a more potent topical steroid; in severe cases, systemic therapy may be
needed. After the dermatitis is controlled, it is important to continue to avoid topical
products such as cleansers/moisturizers with the suspected or known sensitizers. If a
moisturizer is needed, white petrolatum is a good option and normal saline is a good
option for cleansing the skin and wounds. |
|
|
Term
| 8. Explain why Unna's Boots are not recommended for non-ambulatory patients with LEVD. |
|
Definition
8. Unna’s Boots are most appropriate for ambulating patients because they function by
supporting and augmenting the calf muscle pump. |
|
|
Term
9. What therapies are considered the cornerstones for effective treatment of ulcers due to
LEVD? |
|
Definition
9. Compression therapy and elevation are considered to be the cornerstones of effective
treatment for patients with LEVD or ulcers due to LEVD. The first priority in
management is to improve venous return and a key to that is preventing/ reducing
edema. Compression increases interstitial tissue pressures, which prevents leakage of
fluid out of the capillaries into tissues, supports re-absorption of fluid back into the
blood stream, and leads to reduction/elimination of edema. Also, compression
partially collapses the superficial (dilated veins), which reduces the diameter of the
vessels and increases the velocity of the blood flow. Elevation contributes to venous
return through the effects of gravity; in order for elevation to be effective, the legs
must be elevated above the level of the heart. |
|
|
Term
10. For a patient with LEVD and normal arterial perfusion, what level of compression (mmHg at
the ankle) is considered to be therapeutic? |
|
Definition
10. Most studies indicate that at least 30 mmHg compression is needed at the ankle. The
therapeutic level of compression for LEVD is considered to be 30-40 mmHg pressure
at the ankle. |
|
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Term
11. How do elastic vs. inelastic products differ in requirements for ambulation and levels of
compression? |
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Definition
11. Because of their stretch and recoil capability, elastic compression products are able to
adapt to changes in the size of the leg volume that occurs with activity (i.e., muscle
contraction) and during rest (i.e., muscle relaxation). Elastic compression exerts
external pressure while the leg is at rest as well as when the calf muscle expands
during ambulation. Elastic products are appropriate for individuals with limited
ambulation and for those who are sedentary because they maintain a therapeutic level
of compression during activity as well as during rest. Inelastic products do not expand during ambulation because they have little to no
stretch or recoil ability. With inelastic compression, pressure is created by the muscle
pressing against the semi-rigid bandage during ambulation when the calf muscle
expands. At rest there is no calf muscle pump activity, and therefore limited
compression is achieved with inelastic products during rest. |
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Term
| 12. Name 2 options for delivering compression at/or below 30 mmHg. |
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Definition
12. For patients who have mixed arterial and venous disease, with an ABI > 0.50 to <
0.80, a reduced level of compression to 23-30 mmHg is recommended. Reduced
levels of compression can be achieved by simple, cost-effective methods such as
using a reusable, elastic tubular sleeve that when measured and applied correctly as a
double layer provides approximately 20 mmHg. Several manufacturers have “light
compression” systems that when applied provide at/or below 30 mmHg. Often the
light system is achieved in a 3 or 4-layer multilayer wrap system by eliminating the
figure-of-eight layer. Therapeutic support stockings can also be used for maintenance
therapy and ordered at 30 mmHg or less. |
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Term
13. Name one adjunctive therapy that can benefit patients with recalcitrant wounds due to
LEVD |
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Definition
13. For patients whose wounds do not heal despite proper therapy, adjunctive therapies
such as application of a human skin equivalent (i.e., tissue engineered skin substitute)
can be considered. Also, in chronic wounds, such as ulcers due to LEVD, enzymes
(matrixmetalloproteinases [MMPs]) that are beneficial during the inflammatory phase
of healing can interfere with granulation tissue formation and delay healing. In such
cases, dressings that inactivate or reduce the levels of MMPs may be helpful. |
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Term
| 14. Describe a positive Stemmer sign and identify what it indicates. |
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Definition
14. A positive Stemmer sign is a clinical indicator of lymphedema. In performing the
Stemmer test, the clinician pinches a fold of skin at the base of the second toe on the
dorsal aspect of the foot. Skin that cannot be pinched up into a fold is considered a
positive sign (positive Stemmer test) of lymphedema, which is a chronic disease
characterized by high protein edema due to impaired lymph flow. |
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Term
15. Weeping, itching, crusting vesicles on edematous, erythematous, tender skin in patients with
LEVD are most characteristic of which of the following conditions?
A. Cellulitis
B. Contact dermatitis
C. Yeast infection
D. Herpes shingles |
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Definition
15. B The hallmark symptoms of dermatitis are severe itching and a red, weeping rash
on the skin. The dermatitis requires treatment with an anti-inflammatory agent
(steroid). In contrast to dermatitis, cellulitis is a bacterial infection of the skin with
symptoms of pain, swelling, redness, and other symptoms of infection, and requires
antibiotic therapy. Yeast infection is characterized by a pruritic, macular-papular rash
with pustular tops that often has satellite lesions and requires treatment with an
antifungal agent. Shingles (herpes zoster) is characterized by severe, burning pain and
clustered fluid-filled vesicles that follow a dermatome distribution, and is treated
customarily with systemic antiviral medications. |
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Term
16. Edema extending from the toes to the groin is most characteristic of which of the following
conditions?
A. Heart failure
B. Kidney failure
C. Venous disease
D. Lymphedema |
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Definition
16. D Lymphedema of the lower extremities is characterized by edema that extends
from the feet/toes, to above the knee and to the groin. Patients with heart and kidney
failure have more generalized edema that would not be localized just in the lower
limb. Edema that extends from the ankle to the knee is characteristic of LEVD. |
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Term
17. Which of the following is an appropriate level of compression for a patient with LEVD and
an ABI of 0.70?
A. 60 mmHg
B. 50 mmHg
C. 40 mmHg
D. 25 mmHg |
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Definition
17. D Patients with an ABI less than 0.80 should have compression at 30 mmHg or less
(no higher than 30 mmHg). If the ABI is < 0.50, no compression should be applied
and the patient should be referred for a vascular evaluation if not already done. |
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Term
18. In which of the following cases is compression therapy contraindicated?
A. ABI 0.40
B. TBI 0.70
C. ABI 1.20
D. ABI 0.80 |
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Definition
18. A Compression is contraindicated with an ABI of 0.40, which is considered critical
ischemia. Compression is indicated for a patient with LEVD and an ABI at/or above
0.80 or a TBI (toe brachial index) of 0.70 which is within a normal range. |
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Term
True/False:
1. ___ Hyperglycemia causes nerve damage, leading to unrecognized repetitive trauma that
can result in foot ulcers. |
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Definition
1. T Hyperglycemia increases glucose migration into nerve cells where it is converted
to sorbitol; the osmotic effects of sorbitol cause edema of the cell and compromised
nerve function. Due to the nerve damage, patients experience motor, sensory and
autonomic neuropathy. Foot ulcers then can occur due to the combined effects of
neuropathy, which include the following: a loss of sensation with risk of painless
trauma; altered foot contours and deformities that result in increased pressure/trauma;
and osteopenia along with reduced sweating and dryness of the skin. Approximately
50% of patients with diabetes have neuropathy. |
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Term
True/False:
2. ___ The typical location of the neuropathic ulcer is on the gaiter area of the ankle. |
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Definition
2. F The typical locations of ulcers due to LEND are on the following areas: Plantar
surface (bottom) of the foot, heels, tips/tops of toes, between toes, on metatarsal
heads, and on areas where callus has formed. |
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Term
True/False:
3. ___ Hyperbaric oxygen therapy is indicated for Grade III diabetic foot ulcers with
osteomyelitis. |
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Definition
3. T A Wagner Grade III diabetic foot ulcer is a deep ulcer with osteomyelitis, abscess
or joint sepsis. Hyperbaric oxygen therapy is an approved therapy for a Grade III
diabetic foot ulcer with osteomyelitis. |
|
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Term
| 4. Name 2 indicators of sensory neuropathy: |
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Definition
4. Due to the damage to sensory nerves, patients with LEND present clinically with a
loss of the ability to sense vibration and loss of protective sensation (ability to sense
pain, pressure, and temperature). They also lose proprioception (i.e., position sense)
and cannot tell the position of their feet, which leads to gait problems and increased
risk for falls. |
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Term
5. What are two methods to screen patients with diabetes for loss of protective sensation
(LOPS) on their feet? |
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Definition
5. Screening for loss of protective sensation on the feet of patients with diabetes/LEND
can be accomplished by using a 5.07, 10 Gm Semmes-Weinstein monofilament and a
tuning fork. Using the monofilament, sensation is checked over 10-12 sites on each
foot over intact skin. Loss of sensation at any one site indicates a foot at high risk for
injury and ulcers. The tuning fork is used to screen for loss of vibratory sensation
over the base of the great toe at the first metatarsal bone. Vibratory sense can be
assessed as either present or absent, or it can be determined to be abnormal if the
patient cannot feel the vibration while the examiner still feels the vibration.
Additional screening tests that can be performed include checking ankle reflexes with
a percussion hammer and assessing proprioception (position sense). Proprioception in
the feet can be assessed by asking the patient to close his or her eyes, moving the
patient’s great toe, and asking whether the movement was up, down, to the left, or to
the right. |
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Term
| 6. What is considered the “gold standard” for offloading foot ulcers due to LEND? |
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Definition
6. Total contact casts (TCC) are considered the gold standard for off-loading of foot
ulcers due to LEND. They must be applied by highly skilled clinicians with
WTA Review Question Answers: Lesson 14
WTA Program: wta@wocn.org
2
training/education in the technique. TCC are highly effective for redistribution of
weight and are used to reduce/eliminate pressure for patients with plantar ulcers. It is
similar to casting except with minimal padding to allow for total contact with the cast
materials; in addition, the toes are enclosed. In a TCC, the foot is immobilized and
stress forces are evenly distributed over the lower limb. |
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Term
7. What is the recommended target range for premeal glucose levels for the patient with
diabetes and a foot ulcer due to LEND? |
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Definition
7. It is recommended that patients with diabetes and an ulcer due to LEND maintain
premeal glucose levels of 80-130 mg/dl to prevent the progression of neuropathy and
the negative effects of hyperglycemia on healing and risk of infection.
Hyperglycemia decreases growth factor function, collagen synthesis, epithelialization,
and white blood cell function. |
|
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Term
| 8. Name 5 activities that patients with diabetes/LEND should be taught for proper foot care: |
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Definition
8. Patients with diabetes/LEND are at high risk for foot problems and should be
educated about their risks and how to manage the risks. Patient education should
focus on the necessity of proper foot care and shoe wear and early identification and
reporting of foot problems. Because of loss of sensation (pressure, temperature, pain,
etc.), it is necessary that the patients be taught the following: inspect their feet daily to
check for trauma/ injuries; wear protective foot wear at all times (e.g., even in the
house); shake out shoes to check for foreign objects that might cause injury; gradually
break in new shoes; float heels off the bed if bed bound; check feet for increased
areas of localized temperature; check water temperature before stepping into a tub or
shower; do not perform bathroom surgery (e.g., using razors or other sharp devices to
trim nails/callus); moisturize skin to prevent cracks/fissures, but do not moisturize
between toes, which can cause maceration and increase the risk of fungal infections;
avoid walking on hot surfaces; wash feet and dry well between toes to prevent
maceration; wear correctly fitted shoes; avoid high heels; obtain professional
nail/callus management; promptly report ulcers or increased pain, etc. |
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Term
| 9. What is the primary factor in managing a plantar wound in patients with diabetes/LEND? |
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Definition
9. Patients with LEND have breakdown in areas commonly exposed to painless,
repetitive trauma, friction, and pressure. Repetitive stress results in inflammatory
changes in the tissues. With loss of protective sensation, patients are unaware of
problems and do not alter their gait or foot wear as would a person with intact
sensation; this can result in ulcer development. Therefore, the key factor to enhance
healing is to offload and redistribute the pressure so the wound can begin to heal. |
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Term
| 10. What is the most common cause of ulcers due to LEND? |
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Definition
10. Due to the combined effects of LEND (i.e., sensory, motor, autonomic neuropathy),
patients are at high risk for the development of ulcers on the feet from repetitive
trauma (friction, pressure, etc). Patients with LEND experience loss of sensation,
vibration and position sense, and may develop altered foot structure and
biomechanics, which leads to abnormal gait patterns. The combination of altered
weight bearing and loss of protective sensation results in repetitive trauma.
Commonly ulcers occur on the plantar aspect of the foot under the metatarsal heads
where the fat pads have thinned; on the plantar aspects of feet where calluses have
formed from toe or foot deformities or altered gait; on areas where the shoes rub on
WTA Review Question Answers: Lesson 14
WTA Program: wta@wocn.org
3
the back and sides of the heels or tips/tops of the toes; and between the toes from
pressure or friction (e.g., especially with excess moisture). |
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Term
11. Explain why patients with diabetes/LEND are at increased risk for burns from foot soaks,
walking on hot pavement, etc. |
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Definition
11. Both sensory and autonomic neuropathy create a risk of burns for patients with
diabetes/LEND. The damage to sensory nerves impairs the ability to sense
temperature changes so they might stand on a hot surface, use a hot water bottle, or
walk on a hot beach and sustain burns. Due to autonomic nerve damage, the nerves
that control the sweat glands and diameter of the blood vessels are impaired.
Sweating and vasodilation are mechanisms the body uses for cooling. Due to
autonomic neuropathy, sweating and vasodilation are impaired and the tissues are
unable to cool the tissues, increasing the risk of burns. |
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Term
Multiple Choice:
12. Which of the following is/ are characteristic of Charcot foot?
A. Warm foot with rocker bottom shape
B. ABI = 0.90
C. Normal sensation
D. Ulcer on dorsal aspect of foot |
|
Definition
12. A The combined effects of sensory and autonomic neuropathy are thought to lead to
development of a Charcot foot. Abnormal blood flow in LEND from autonomic
neuropathy can lead to a loss of bone density with increased risk for Charcot’s foot,
which begins with an unrecognized fracture. The arch of the foot can collapse
creating a protrusion in the mid-portion of the plantar surface of the foot (i.e., rocker
bottom shape), and presents clinically with a warm foot with intact skin. The ABI is
an indicator of arterial circulation of the lower limb and is not a characteristic of
Charcot fracture. Patients with Charcot foot would be expected to have a loss of
protective sensation. Charcot foot (fracture) can occur in the absence of any open
ulceration. If the patient walks on the Charcot fracture, it can ulcerate underneath
with a wound occurring on the plantar surface of the foot, in the mid foot area and not
on the dorsum of the foot. |
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Term
13. Dry, cracked skin on the feet of patients with diabetes is most likely due to which of the
following?
A. Fungal infection
B. Poor oral intake
C. Motor neuropathy
D. Autonomic neuropathy |
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Definition
13. D Dry, cracked skin and fissures on the feet of patients with diabetes commonly
occur due to autonomic neuropathy from damage to the nerves that control sweating
and vasodilation. Dry, cracked skin alone, without other symptoms, would not be
characteristic of a fungal infection. Fungal infections commonly thrive in moist
environments and present with itching, scaling of the skin, and erythema. Severe
fungal infections can result in denuded skin or eruptions (vesicles or bullae). Poor
oral intake would not cause localized dry skin just on the feet—it would be
generalized over the body. Motor neuropathy damages nerves that control the muscles
of the foot causing muscle atrophy and foot deformities, but it would not cause
dryness of the skin. |
|
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Term
14. Which diagnostic test is most conclusive for osteomyelitis?
A. Swab culture
B. Bone biopsy
C. Complete blood count
D. X-ray |
|
Definition
14. B A bone biopsy is the gold standard, most conclusive test to diagnose
osteomyelitis. Swab cultures are not reliable to detect bone infections as they would
only be able to sample surface organisms vs. obtaining a sample of the organisms
invading the bone. A CBC (complete blood count) would not be specific to a bone
infection as it would be elevated in many types of infections. X-rays have high levels
of false negative results in osteomyelitis because it takes about 20 days for the bone
changes to be visible and appear on an X-ray. |
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