practice wounds

What patient situation is considered high risk for developing an unavoidable pressure injury?

End of life with severe perfusion impairment.

High output fistula vs moderate vs low

High is >500cc/24hrs

Moderate is 200-500cc/24hrs

Low is <200cc/24hrs

Colovesicle

Stool draining from colon into bladder

Rectovaginal

Stool draining form rectum into valine

Enterocutaneous

Small bowel contents draining onto skin

Enteroatmospheric

Small bowel draining into open wound

Internal Fistula

One loop of bowel draining into another loop or between other internal structures

External Fistula

Internal organ draining onto skin or outside of the body, like jejunorectal, rectovaginal

Simple Fistula

Fistula with short tract and no abscess and no other organ involvement

Complex Fistula type 1

With an abscess and multiple organ involvement

Complex Fistula type 2

Opens into the wound base

A patient with metastatic breast cancer is admitted with a fungi, Canadian mass and rates pain at nine out of 10 during dressing changes. Which is the best approach for her?

Use non-adherent dressings. Measures to ensure comfort with dressing changes for those with fungating wounds include medicating prior to dressing changes, the use of non-adherent dressings and decreased frequency of dressing changes.

A patient with history of Crohn’s disease has a painful, full thickness ulcer to the right lower leg. The ulcer has a violaceous border and a necrotic wound bed. What is the most likely condition?

Pyoderma Gangrenosum. The hallmark for this condition is an ulcer with a raised, dusty, red or purpleish border that is inflamed, frequently undermined, and has a boggy, necrotic base. There is frequently pure drainage and a bright halo of erythema, extending about 2 cm from the ulcer border. About half of patients have coexisting systemic inflammatory disease, with the most common being inflammatory bowel disease.

What is the most appropriate intervention for treating a stage 1 pressure injury?

Turn and reposition frequently off the area. Non-blanchable erythema is indicative of some level of tissue damage and inflammation involving the skin and soft tissues; non-blanchable erythema over a bony prominence is classified as a stage one pressure injury. It is important to provide offloading and to monitor the intensity of erythema and the blanch response as an ongoing measure of treatment success.

What is an effective method to minimize the adverse effects of shearing?

Elevate head of bed to 30 degrees or less when positioning in semi-fowler's position to minimize the risk of shearing that comes from sliding down in bed.

What is the initial effect of sustained pressure on a body part?

Tissue and blood vessel compression. Sustained pressure applied to soft tissues causes tissue deformation and ischemia.

The burn team initially focuses on the zone of stasis when planning wound care. What is the rationale for this strategy?

Tissue damage in this area is potentially reversible. It is characterized by decreased tissue perfusion, resulting in transient ischemia. So it is potentially reversible with appropriate fluid resuscitation. Initial management of burn injury focuses on this zone to preserve as much tissue as possible.

What is the initial classic type of pain associated with lower extremity arterial disease?

Intermittent claudication. This is reproducible pain brought on by walking or similar activities and relieved by about ten minutes of rest.

What findings would indicate a fistula requires surgical closure?

Evidence of mucosal pseudostoma

A patient develops a recurrent pressure injury over the ischial tuberosity. What is the most likely explanation for this problem?

Inadequate pressure redistribution. Individuals who remain seated for prolonged periods of time are predisposed to pressure injury development, particularly in the ischial area. Pressured redistribution chair cushions should be used with seated individuals who are at risk for pressure injury and have reduced mobility.

A Stage 3 pressure injury with moderate amounts of drainage should have a dressing from which topical treatment category.

Hydrofiber dressings as they have the ability to absorb large amounts of exudate and are therefore indicated for use in a variety of wounds with moderate to heavy exudate.

A patient has a moderately draining venous ulcer. Assessment demonstrates pitting edema of the ankle with an ABI of 1.0. She reports that her job requires her to be on her feet most of the day. Which of the following is the most appropriate intervention?

Foam dressing and multilayer compression wraps. Foam dressings are appropriate for wounds with low to moderate volume exudate and for heavily exudating wounds. They are a good choice for highly exudating lower extremity ulcers. Compression therapy remains the mainstream approach for both treatment and prevention for LEVD. The category of elastic compression includes two, three, or four component disposable layers. Absorption of exudate is another advantage of the multi-component wrap.

Which topical treatment is most appropriate for a patient with a full thickness pressure injury with undermining?

Hydrogel impregnated gauze: It is often non-adherent to the wound bed. and it can be opened and fluffed to loosely fill the wound depth. Gauze should usually be moistened prior to placement in contact with the wound bed. If used as a primary dressing in contact with the wound bed, it is essential to adhere to the following guidelines. Use a non-woven gauze, moisten the gauze, and fluff the gauze loosely into the wound bed. When factoring the time and frequency of change and cost of the person performing multiple dressing changes, the result is a higher cost with gauze.

A patient presents to the emergency department with a scalding burn on the abdomen. Tissue damage is noted to be the most severe with necrosis in the lower abdominal area. This describes which zone of tissue damage.

Zone of coagulation. It is the point of most severe damage. It is where tissue destruction in this area is irreversible due to the coagulation of cells and the denaturing of protein. It is also known as the zone of necrosis.

A patient with a malignant fungiating wound experiences bleeding with each dressing change. Which topical treatment would be best to address this problem.

Calcium alginate dressing. Hydrofibers and alginates minimize trauma and dressing frequencies as compared to gauss type dressings. Alginates have been demonstrated to exhibit hemostatic effects and have been useful for heavily exudating wounds. Atraumatic dressing removal is of paramount importance. If the dressing is adherent to the wound, it should be moistened prior to removal.

A patient with a history of rheumatoid arthritis and coronary artery disease presents with a cluster of tender red nodules with palpable pura pura and a small shallow, well-demarcated non-draining ulcer over the right malleolus. The periwound skin is ecchymotic. Which of the following is the most likely condition?

Vasculitis.

Which lesions are most consistently seen with a Candida Albicans infection on the skin?

Plaques, patches, and satellite lesions. Clinically, ITD with superficial infection of Candida presents as itchy and painful, beefy red, macerated and eroded plaques and patches, often with peripheral scaling and smaller satellite pustules or papules. Commonly affected areas include the inframammary areas, area at the base of the pannus, inguinal folds, gluteal cleft and scrotum.

What is the best method to obtain a wound culture using a swab technique?

Obtain the swab culture from an area of the wound that is free of necrotic tissue.

In patients with venous insufficiency, which situation contraindicates therapeutic static compression?

The patient with an ABI of < 0.5 .

What is a recommended step for changing a fistula pouch?

Trace the pattern onto the skin barrier surface of the pouch leaving at least 1/4 inch clearance.

What is the primary etiology of most enterocutaneous fistulae?

Surgical procedures.

What intervention is appropriate for a wound with moisture-associated skin damage?

Maintain a moist wound bed while keeping periwound skin dry.

Charcot foot deformity is directly related to which condition?

Poor glucose control.

What product is appropriate for managing a fistula?

Pouching system for high or low-output fistula.

What is the best practice for applying enzymatic debridement to a wound with eschar?

Score the eschar with a #10 scalpel blade prior to application.

Which antimicrobial product is effective in preventing postoperative infections in high-risk patients?

Polyhexamethylene Biguanide (PHMB).

In which patient scenario is a reactive support surface with low air loss appropriate?

Multiple stage 2 pressure injuries.

What risk factor for lower extremity venous disease is associated with calf muscle pump dysfunction?

Altered gait.

What type of clothing is safe to use in a hyperbaric oxygen treatment chamber?

Clothing made from 100\% cotton.

What clinical manifestation indicates 3^{rd} -degree frostbite?

Initial presence of violet-hued, hemorrhagic blisters and eventual skin necrosis. 3rd degree frostbite involves freezing injury of the entire skin with extension into the sub Q tissue.

What is the first-line treatment for odor management in fungating wounds?

Topical metronidazole and antimicrobial dressings.

Which type of debridement is appropriate only for non-infected wounds?

Autolysis.

What is the routine tube care for a newly placed PEG tube?

The tube site should be washed daily with mild soap and water, rinsed, and dried.

What is the most important therapy element for patients with chronic venous insufficiency?

Compression therapy to improve venous return.

What is the first intervention for a clogged feeding tube?

Flush the tube with lukewarm water using a 60\text{ ml} syringe and push-pull motion.

What represents the most likely pathology of lymphedema?

Lymphatic vessel damage and filariasis infection.

What condition indicates ischemic skin damage?

Purplish discoloration.

Which statement is accurate regarding pressure injury staging?

Visual inspection alone is prone to error.

Who is the appropriate candidate for hyperbaric oxygen therapy?

Patient with a recalcitrant diabetic foot ulcer.

What does hard and fibrous peri-ulcer skin signify in chronic venous insufficiency?

Lipodermatosclerosis. This is defined as skin changes in the lower leg with induration, fibrosis, and hyperpigmentation, resulting in an inverted champagne bottle appearance to the lower leg. This also represents long-term chronic Venus insufficiency.

What does an ankle-brachial index of 0.9 indicate?

Lower extremity arterial disease (LEAD).

What is an advantage of using a foam dressing on wounds?

Can be used as a primary or secondary dressing.

What is the best odor management for a low output fistula?

Charcoal dressing over current dressing.

What is the most important therapeutic feature of a support surface for pressure injury prevention?

Pressure redistribution.

What is a definitive indicator of impending fistula development?

Passage of GI secretions or urine into an open wound bed.

What is the next step before electrical stimulation therapy for a diabetic foot ulcer?

Review medical record for history of osteomyelitis. osteomyelitis is a contraindication for electrical stimulation therapy and should be ruled out prior to use.

What happens to leeches after they become engorged?

The leeches will disengage from the host once engorged with blood. If that doesn’t spontaneously occur, topical lidocaine can be applied to paralyze the leeches, then manually remove.

What assessment is being performed when the patient's hallux is moved in different directions while their eyes are closed?

Proprioception.

What is the primary focus of care during the emergent phase of a burn injury?

Hemodynamic stabilization. The first 72 hours after a burn is considered the emergent phase which focuses on hemodynamics stabilization through fluid resuscitation and early wound management.

What is the most frequent etiology for Steven-Johnson syndrome and toxic epidermal necrolysis?

Drug reactions.

What type of skin injury can occur from vigorous rubbing while cleansing the perineal area?

Friction, it is described as the “continuous or repetitive movements, rubbing or sliding of a material..”

Negative pressure wound therapy is indicated for which wound types?

Skin flap closures and pressure injuries.

What should a nurse do if they note black foam sticking to the wound bed during NPWT?

Add a contact layer to the wound bed prior to next dressing change.

What is the best method to administer medications via percutaneous feeding tube?

Flush with 15\text{ ml} of water before and after each medication.

Which skin type is most vulnerable to pressure injury?

Hot, wet skin.

What intervention is recommended for treating large blisters in bullous pemphigoid?

Puncture and drain large blisters in a sterile environment. The epithelial roof should be left intact after drainage to provide wound coverage.