CM - Wound Care 2

risk

The Wound Healing Index (WHI) is a _____ stratification tool for all wounds

• devitalized tissue

• infection/inflammation

• moisture balance

• edge effect

the DIME framework stands for:

TRUE

True/False: Determining whether a wound is healable, maintenance, or non‑healable is part of the POC paradigm

• debridement

• infection/inflammation control

• moisture balance

• edge effect

Local wound care (based on dime) includes: (4)

FALSE - they are included

True/False: Patient and family‑centered concerns are not part of the wound bed preparation paradigm

debridement

Before __________, clinicians should consider blood flow, patient tolerance, and PT tolerance

24

Sterile saline used for wound cleansing must be used within ___ hours of opening

FALSE - NON CYTOTOXIC and compatible with most dressings

True/False: Hypochlorous acid (HOCl) is cytotoxic and compatible with most dressings

TRUE

True/False: Hydrogen peroxide is cytotoxic and is not recommended for wound cleaning

TUNNELING, UNDERMINING

Pulsed lavage with suction is contraindicated in wounds with __________ or ______________

FALSE

True/False: Scrubbing the wound with abrasive material is recommended to remove debris

re-epithelialization

HOCl can reduce pain and itching and accelerate _____ compared to saline

selective

Autolytic debridement is _____ but slow

TRUE

True/False: Autolytic debridement is contraindicated in infected wounds

autolytic

__________ debridement is mother nature’s natural process

enzymatic

_______ debridement uses topical enzymes and is faster than autolytic debridement

FALSE (enzyme cannot be used with silver or iodine dressing)

True/False: Enzymatic debridement can be used with silver dressings

non-selective

mechanical debridement is (selective/non-selective)

FALSE - very painful

True/False: Wet‑to‑dry dressings are standard of care for mechanical debridement.

painless

Monofilament pads are described as basically _________

TRUE (tb to tawny)

True/False: Whirlpool is no longer standard of care due to infection risk

TRUE

True/False: Ultrasonic debridement can disrupt biofilm

selective

__________ debridement uses sharp instruments such as scalpel, scissors, forceps, and curette

new structure

Selective debridement should stop when all non‑viable tissue is removed or when a ________ is exposed

3

INR over ______ is a contraindication to selective debridement

maggot larvae

biologic debridement uses sterile ______________

FALSE - typically painless

True/False: Biologic debridement is typically painful

infection

the gold standard for diagnosis ________ is a tissue biopsy

superficial infection

NERDS is the clinical signs of critical colonization, which is also called ________________

• non healing wound

• exudative wound

• red and bleeding granulation (friable)

• debris on wound surface

• smell or unpleasant odor

NERDS stands for:

FALSE - nerds = superficial infection, treat topically

True/False: NERDS signs indicate deep infection requiring systemic treatment

DEEP

STONES signs indicate ______ infection

• size is bigger

• temperature increases

• Os- probe to or exposed bone

• new or satellite areas of breakdown

• exudate, erythema, edema

• smell

STONES stands for:

systemic treatment, surgical intervention

treatment for deep infection includes _____________ or ________________

FALSE

True/False: Biofilm responds well to antibiotics

6-12

Biofilm can form in ___-___ hours

TRUE

True/False: Cadexomer iodine is effective against biofilm

• silver

• cadexomer iodine

• manuka honey

three types of antimicrobials are:

bacterial resistance, disposal

the two concerns using antimicrobial silver dressings are __________ and ___________

dental plaque

biofilm is similar to ________ in that it cannot be rinsed or wiped away

physical removal, scraping

the treatment goal with bacterial biofilm is to disrupt via ___________ and _________ and PREVENT future biofilm

chronic

bacterial biofilm has a much higher prevalence in (acute/chronic) wounds

infections

bacterial biofilm is a problem because it prevents healing by causing more ___________

moist

_______ wound healing results in faster closure, less scarring, lower infection risk, and less pain

TRUE

True/False: Hydrogel is appropriate for dry or scant drainage wounds.

maceration

there is a risk of ________ with moisture donating dressings, so apply every 1-2 days

hydrocolloid

__________ is good for partial thickness or shallow full thickness wounds with minimal to moderate exudate

gelling

Hydrofiber and alginate dressings have _____ properties and are used for moderate to copious drainage

TRUE

True/False: Negative Pressure Wound Therapy increases perfusion and granulation tissue formation

fill

don’t pack the wound, ______ the wound