Simulation: Skills Modules 3.0Module: Wound Specimen collection & Wound Care

Flashcard 1: Wound Specimen Collection

• Question: What are the general steps to collect a wound specimen?

• Answer: Perform hand hygiene, wear clean gloves, and if the wound is bandaged, remove the dressing and clean the wound with sterile water or 0.9% sodium chloride solution. Then, collect the specimen from the center of the wound using a sterile swab or syringe.

Flashcard 2: Avoid Collecting from Edges

• Question: Why should you avoid collecting a wound specimen from the edges of the wound?

• Answer: The edges of the wound may be contaminated with outside skin flora, which can lead to inaccurate results. Always collect specimens from the center of the wound.

Flashcard 3: Handling Drainage

• Question: Where should you avoid collecting wound drainage from?

• Answer: Never collect drainage from pus or pooled exudates as they may not represent the true infection site.

Flashcard 4: Specimen Collection with a Swab

• Question: How do you collect a wound specimen using a sterile swab?

• Answer: Use a sterile swab to obtain the sample from the center of the wound. Place the swab into a sterile test tube, ensuring it does not touch the edges of the test tube. Break the ampule, place the sample in the test tube medium, and secure the lid.

Flashcard 5: Transporting the Specimen

• Question: How should you handle and transport the wound specimen?

• Answer: After securing the lid on the test tube, label the sample and prepare it for transport to the laboratory. Check with the laboratory for proper collection, storage, and transport time.

Flashcard 6: Documentation

• Question: What should you document when collecting a wound specimen?

• Answer: Document the assessments, vital signs, date, time, location, and the client's tolerance of the procedure in the client's medical record.

Flashcard 7: Avoiding Mislabeling

• Question: Why is accurate labeling important when collecting a wound specimen?

• Answer: Inaccurate collection or mislabeling can lead to repeated collections and misdiagnosis, which can delay appropriate treatment.

Flashcard 8: Requisition Form

• Question: What should accompany the wound specimen when transported to the laboratory?

• Answer: A completed requisition form with the necessary details should be sent to the laboratory with the specimen.

Flashcard 1: Wound Specimen Testing

• Question: What is the primary purpose of processing wound specimens in the laboratory?

• Answer: The primary purpose is for culture and sensitivity testing, which helps identify the bacteria present and determine the most effective antibiotic therapy.

Flashcard 2: Two-Step Testing Process

• Question: What is the two-step testing process for wound specimens?

• Answer: The two-step process involves determining the type of bacteria in the wound and testing the wound's sensitivity to various antibiotics to guide appropriate therapy.

Flashcard 3: Contamination in Wound Cultures

• Question: What is a common issue when processing wound cultures, and how is it addressed?

• Answer: Wound cultures can be contaminated with flora from the surrounding skin. If this occurs, a repeat culture is often recommended to ensure accurate results.

Flashcard 4: Antibiotic Therapy and Culture Timing

• Question: Why is it recommended to obtain a wound culture prior to initiating broad-spectrum antibiotics?

• Answer: To avoid altering test results due to the presence of antibiotics, which may affect bacterial growth or sensitivity, making it difficult to identify the right treatment.

Flashcard 5: Indicating Current Antibiotic Use

• Question: Why should you indicate if a client is already receiving antibiotics on the laboratory requisition form?

• Answer: Indicating current antibiotic use helps the laboratory interpret the results accurately, as antibiotics can alter the outcome of the culture and sensitivity test.

Flashcard 6: Waiting for Results Before Prescribing

• Question: Why do many providers wait for wound culture results before prescribing antibiotics?

• Answer: With increasing concerns about medication resistance, waiting for the results allows for more targeted and appropriate antibiotic therapy.

Flashcard 7: Gram Stain for Faster Diagnosis

• Question: What is a Gram stain, and how does it help in treating a wound infection?

• Answer: A Gram stain is a quick test that can be requested to analyze drainage from the wound. It helps identify bacteria sooner, allowing healthcare providers to prescribe appropriate treatment more quickly.

Flashcard 1: Wound History

• Question: What key aspects should you inquire about when taking a wound history?

• Answer: Ask about the onset of the wound, any acute injury or known cause, associated manifestations (pain, itching), changes over time, and major health problems that may affect wound development or healing.

Flashcard 2: Frequency of Wound Assessment

• Question: How often should wounds be assessed?

• Answer: Wounds should be assessed at each dressing change to monitor for progress or deterioration, but the frequency of assessment may vary based on the wound's acuity and facility guidelines.

Flashcard 3: Visual Wound Assessment

• Question: What should be assessed visually when examining a wound?

• Answer: Visually assess location, shape, size, color, exudate, bleeding, and the presence of necrosis, erythematous tissue, or infected tissue. Also look for tunneling, undermining, edema, and healthy tissue like granulating tissue or clean wound edges.

Flashcard 4: Temperature and Textural Changes

• Question: What temperature and textural changes might be noted during a wound assessment?

• Answer: Temperature changes range from warm (indicating infection) to cold (indicating vascular compromise). Textural changes could include roughened or raised skin, or deep wounds that disrupt the skin's natural contour.

Flashcard 5: Odor in Wound Assessment

• Question: Why is odor important in wound assessment?

• Answer: Odor can indicate specific infectious organisms or help identify the cause of the wound, making it a key factor in assessing the wound's condition.

Flashcard 6: Periwound Skin Condition

• Question: What should you assess in the periwound area during a wound assessment?

• Answer: The condition of the skin surrounding the wound (periwound skin) should be examined for signs of irritation, breakdown, or infection.

Flashcard 7: Psychosocial Impact

• Question: Why is assessing the psychosocial impact of a wound important?

• Answer: It's important to evaluate the client’s response to the wound, considering stress, body image, self-concept, and sexuality, as well as the resources available to help them adapt.

Flashcard 8: Wound Assessment Scales

• Question: What are wound assessment scales used for?

• Answer: They are used to assess risk for pressure injuries and to monitor the healing process of existing wounds.

Flashcard 9: Wound Measurement

• Question: How should wounds be measured during an assessment?

• Answer: Wounds should be measured in length, width, and depth using rulers or other measuring tools. Tunnelsand areas of undermining should be measured separately.

Flashcard 10: Pressure Injury Staging

• Question: How are pressure injuries classified?

• Answer: Pressure injuries are classified using six stages, but these stages are specifically for pressure injuriesonly.

Flashcard 1: Definition of Pressure Injury

• Question: What is a pressure injury?

• Answer: A pressure injury is an area of compromised skin integrity over a bony prominence resulting from prolonged pressure. Common sites include the occipital bone, sacrum, heel, trochanter, and malleolus.

Flashcard 2: Common Pressure Injury Sites

• Question: What are the most common sites for pressure injuries?

• Answer: The most common sites are the occipital bone, spinous process, sacrum, ischium, heel, trochanter, and lateral and medial malleolus.

Flashcard 3: Risk Factors for Pressure Injury

• Question: What factors increase the risk for pressure injury development?

• Answer: Factors include friction, shear, moisture, altered sensory perception, consciousness, and inadequate nutrition.

Flashcard 4: Friction and Shear

• Question: What is the difference between friction and shear in pressure injuries?

• Answer: Friction occurs when skin rubs against a surface, irritating the epithelial tissue. Shear happens when the skin stays in place, but the subcutaneous tissues shift, stretching blood vessels and causing soft-tissue ischemia.

Flashcard 5: Example of Shear

• Question: What is an example of shear in pressure injuries?

• Answer: An example is when a client slides downward in bed, causing the sacrum to move faster than the skin over it, resulting in stretching and blood vessel breakage.

Flashcard 6: Reducing Shear Risk

• Question: How can the risk of shear be reduced?

• Answer: The risk of shear can be reduced by keeping the head of the bed no higher than 30 degrees.

Flashcard 7: Moisture and Pressure Injuries

• Question: How does moisture affect pressure injury development?

• Answer: Moisture reduces skin's resistance to friction and shear, increasing the risk of breakdown. Body fluids like urine, feces, wound drainage, and perspiration can contribute to moisture-related damage.

Flashcard 8: Sensory Perception and Pressure Injuries

• Question: How does altered sensory perception impact pressure injury risk?

• Answer: Clients with altered sensory perception or consciousness may not be able to detect, communicate, or respond to pressure, increasing their risk for pressure injuries.

Flashcard 9: Nutrition and Pressure Injuries

• Question: How does inadequate nutrition affect the development of pressure injuries?

• Answer: Inadequate nutrition can weaken the skin and reduce its ability to repair itself, increasing the risk for pressure injury development. Consultation with a dietitian may be necessary.

Flashcard 10: Repositioning for Pressure Injury Prevention

• Question: Why is repositioning important for preventing pressure injuries?

• Answer: Repositioning is essential for preventing pressure injuries in clients with limited or complete immobility. This should be done regularly, both when the client is sitting and in bed.

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Flashcard 1: NPIAP Pressure Injury Staging Overview

• Question: What are the six classifications of the National Pressure Injury Advisory Panel's (NPIAP) pressure injury staging system?

• Answer: The six classifications are:

  • Suspected deep tissue injury (not a stage, but discolored intact skin due to underlying tissue damage)

  • Stage 1: Nonblanchable redness over a bony prominence

  • Stage 2: Partial-thickness skin loss with visible injury or fluid-filled blister

  • Stage 3: Full-thickness tissue loss without exposed muscle or bone, may have undermining or tunneling

  • Stage 4: Full-thickness tissue loss with exposed muscle or bone, possible undermining or tunneling, eschar or slough may be present

  • Unstageable: Wound stage cannot be determined due to eschar or slough obscuring the wound

Flashcard 2: Suspected Deep Tissue Injury

• Question: What is a suspected deep tissue injury in pressure injury staging?

• Answer: A suspected deep tissue injury is an area of discolored intact skin caused by damage to underlying tissue, but it is not considered a stage in the NPIAP system.

Flashcard 3: Stage 1 Pressure Injury

• Question: What characterizes a Stage 1 pressure injury?

• Answer: Stage 1 is defined by nonblanchable redness typically over a bony prominence, indicating pressure-induced damage to the skin.

Flashcard 4: Stage 2 Pressure Injury

• Question: What defines a Stage 2 pressure injury?

• Answer: Stage 2 involves partial-thickness skin loss, which includes visible injury or the formation of a fluid-filled blister.

Flashcard 5: Stage 3 Pressure Injury

• Question: What is a Stage 3 pressure injury?

• Answer: Stage 3 involves full-thickness tissue loss without exposure of muscle or bone. It may also include undermining or tunneling.

Flashcard 6: Stage 4 Pressure Injury

• Question: What is characteristic of a Stage 4 pressure injury?

• Answer: Stage 4 involves full-thickness tissue loss with exposed bone or muscle, with the possibility of undermining or tunneling, and the presence of eschar (black scab-like material) or slough (yellow/white dead tissue).

Flashcard 7: Unstageable Pressure Injury

• Question: What does unstageable mean in pressure injury staging?

• Answer: An unstageable injury occurs when eschar or slough obscures the wound, making it impossible to determine its stage.

Flashcard 8: The Braden Scale

• Question: What is the Braden Scale used for?

• Answer: The Braden Scale is used to assess the risk of pressure injury formation based on six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Flashcard 9: Braden Scale Scoring

• Question: What is the scoring range for the Braden Scale, and what is the cutoff for most adults?

• Answer: The Braden Scale scores range from 6 to 23. A score of 18 or lower generally indicates a higher risk for pressure injury formation in most adults.

Flashcard 10: Risk Interpretation with Braden Scale

• Question: What does a lower score on the Braden Scale indicate?

• Answer: A lower score on the Braden Scale indicates a higher risk for developing pressure injuries.

Flashcard 1: Phases of Wound Healing Overview

• Question: What are the three main phases of wound healing?

• Answer: The three main phases are:

  1. Inflammatory Phase

  2. Proliferative Phase

  3. Maturation Phase

Flashcard 2: Inflammatory Phase

• Question: What occurs during the inflammatory phase of wound healing?

• Answer: The inflammatory phase begins after injury and lasts about 24 hours for partial-thickness wounds. Key characteristics include:

  • Skin color changes

  • Heat, swelling, pain, and loss of function

  • White blood cells (neutrophils, macrophages) help fight infection and promote healing

  • Neutrophils kill bacteria and macrophages secrete growth factors to assist with wound healing

Flashcard 3: Proliferative Phase

• Question: What occurs during the proliferative phase of wound healing?

• Answer: The proliferative phase restores skin integrity by filling the wound with new tissue. It includes:

  • Angiogenesis: formation of new blood vessels

  • Formation of granulation tissue (red, bleeding-prone tissue)

  • Epithelialization: cells migrate to cover the wound

  • Fibroblasts deposit collagen and myofibroblasts help with contraction of the wound edges

  • The formation of a rough scar that is vulnerable to trauma

Flashcard 4: Maturation Phase

• Question: What happens during the maturation phase of wound healing?

• Answer: The maturation phase is the final phase, which can take over a year. Key processes include:

  • Collagen remodeling to increase strength and skin integrity

  • Scar tissue becomes thinner and changes in appearance (e.g., color fades in light skin)

  • In dark skin, scars may be more pigmented than surrounding tissue

Flashcard 5: Intrinsic Factors Affecting Wound Healing

• Question: What are some intrinsic factors that can affect wound healing?

• Answer: Key intrinsic factors include:

  • Age: Thinning epidermis and diminished cell functions

  • Chronic illness: Poor oxygenation and immune function

  • Reduced sensation: Leads to increased injury risk and difficulty healing

Flashcard 6: Extrinsic Factors Affecting Wound Healing

• Question: What are some extrinsic factors that can affect wound healing?

• Answer: Key extrinsic factors include:

  • Medications: Aspirin (inhibits platelets), corticosteroids (suppress immune system)

  • Cancer treatments: Radiation and chemotherapy affect cell function

  • Inadequate nutrition: Lack of protein and vitamins slows healing

  • Stress: Alters the body's ability to respond to injury

  • Repeated trauma or infection: Can delay healing

Flashcard 7: Chronic Wounds and Healing

• Question: How do chronic wounds heal differently from acute wounds?

• Answer: Chronic wounds heal via secondary intention, where:

  • Wound edges don’t approximate (come together)

  • Healing occurs through granulation tissue, wound contraction, and epithelialization

  • Proliferative phase is slower, with inefficient keratinocyte migration and irregular wound edges

Flashcard 8: Secondary Intention vs Primary Intention

• Question: What is the difference between secondary intention and primary intention wound healing?

• Answer:

  • Primary intention: Wound edges are approximated (e.g., surgical wounds), and the wound heals quickly without granulation tissue formation.

  • Secondary intention: Wound edges do not come together and heal through granulation tissue, contraction, and epithelialization.

Flashcard 9: Proliferative Phase in Chronic Wounds

• Question: What is unique about the proliferative phase in chronic wounds?

• Answer: In chronic wounds, the proliferative phase is inefficient, characterized by:

  • Irregular wound edges

  • High concentrations of fluid and proinflammatory cytokines

  • Slower healing due to these factors, along with potential for infection or repeated trauma

Flashcard 10: Maturation Phase in Chronic Wounds

• Question: How is the maturation phase affected in chronic wounds?

• Answer: In chronic wounds, maturation can be delayed due to:

  • Uneven collagen deposition

  • Imbalance in collagen breakdown and synthesis

  • Slow scar remodeling, resulting in weaker, less stable scar tissue

Flashcard 1: Dry Dressings

• Question: What are dry dressings, and when are they used?

• Answer: Dry dressings are typically made from gauze pads and secured with rolled gauze and tape or a self-adherent bandage. They are simple, inexpensive, and work well for wounds with small amounts of exudate. However, they can stick to heavily exudative wounds and expose the wound to the outside environment. They can be used in both sterile and clean environments (e.g., surgical wounds, venous access device sites).

Flashcard 2: Wet-to-Dry Dressings

• Question: What are the issues with wet-to-dry dressings?

• Answer: Wet-to-dry dressings, which were once used for debridement, have several disadvantages:

  • Nonselective: They remove healthy tissue along with necrotic tissue.

  • Painful to remove.

  • Time-consuming and costly due to frequent dressing changes.

  • Maceration: The moisture causes surrounding tissue damage.

  • Cross-contamination risk: The saturated gauze does not form a barrier.

• Recommendation: Do not use in clean wounds with granulation tissue.

Flashcard 3: Chemical-Impregnated Dressings

• Question: What are chemical-impregnated dressings, and when should they be used?

• Answer: Chemical-impregnated dressings contain agents like povidone-iodine, silver, petroleum, or antibiotics to enhance healing. These dressings are used only for wounds that will respond to the specific agent. They require careful consideration of cost, availability, and potential allergic reactions before use.

Flashcard 4: Foam Dressings

• Question: What are the benefits of foam dressings?

• Answer: Foam dressings are absorbent, create a moist healing environment, and protect the wound. They provide extra protection for areas like bony prominences. Foam dressings can be self-adherent or nonadherent (requiring securement). Care must be taken to avoid skin damage during application and removal.

Flashcard 5: Alginate Dressings

• Question: What are alginate dressings used for?

• Answer: Alginate dressings, made from seaweed, absorb exudate well and promote a moist environment for healing. They help with hemostasis and are ideal for wounds with heavy exudate. They should not be used on dry wounds and require a secondary dressing to hold them in place.

Flashcard 6: Hydrogel Dressings

• Question: What is the purpose of hydrogel dressings?

• Answer: Hydrogel dressings are absorbent and help maintain a moist healing environment, similar to alginates. They are used for wounds with necrosis and infection. They do not affect hemostasis and should not be used on dry gangrene or dry ischemic wounds. Hydrogel dressings can be costly and must be changed when they become saturated.

Flashcard 7: Wound Fillers

• Question: What are wound fillers, and when are they used?

• Answer: Wound fillers, in the form of pastes, powders, gels, or beads, provide a moist environment beneath dressings and help with debridement. They are beneficial for deep wounds with exudate but less useful for dry wounds.

Flashcard 8: Transparent Film Dressings

• Question: What are the characteristics of transparent film dressings?

• Answer: Transparent film dressings consist of a thin plastic layer that covers the wound. They:

  • Create a barrier to the environment.

  • Promote autolytic debridement.

  • Allow oxygen exchange but do not absorb exudate.

  • Are best for superficial skin tears or necrotic tissue.

  • Can cause maceration and skin damage during removal.

Flashcard 9: Hydrocolloid Dressings

• Question: When are hydrocolloid dressings used?

• Answer: Hydrocolloid dressings are used for autolytic debridement and maintain a moist wound healing environment. They are absorptive and are useful for vulnerable wounds but not for infected wounds. These dressings stay in place for up to 7 days, but should be changed when exudate accumulates.

Flashcard 10: Wound Closure Materials

• Question: What types of materials are used for wound closure?

• Answer: Wound closure materials include:

  • Sutures: Used for deeper wounds; removal time varies with wound location and depth.

  • Staples: Typically removed with a sterile staple remover.

  • Tissue adhesives: Used for superficial wounds or in conjunction with sutures.

  • Wound closure materials can be reinforced with adhesive skin closures after suture or staple removal.

Flashcard 11: Tape

• Question: How is tape used in wound care?

• Answer: Tape is used to secure dressings to wounds. Available in paper, plastic, or cloth varieties, tape should be removed carefully to avoid skin damage. Some tapes leave sticky residue that can be removed with adhesive remover wipes. Always assess the skin for allergic reactions.

Flashcard 12: Binders

• Question: What are binders, and when are they used?

• Answer: Binders provide support to body areas, often used after surgery (e.g., abdominal surgery). They can cause skin irritation or abrasions if not applied properly. Binders should be removed and assessed regularly to avoid discomfort or complications.

Flashcard 13: Topical Wound Agents

• Question: What types of topical wound agents are used in wound care?

• Answer: Topical wound agents include:

  • Antiseptic agents: (e.g., povidone-iodine, silver) to inhibit microorganisms, but some can damage healing tissue.

  • Antibiotic ointments: (e.g., bacitracin, neomycin) to treat infected wounds.

  • Antifungal agents: Used for fungal infections (e.g., nystatin, ketoconazole).

  • Chemical debridement gels: Used for necrotic tissue in pressure injuries.

  • Barrier creams: Prevent skin breakdown from friction, moisture, and pressure.

Flashcard 1: Wound Cleansing

• Question: What is the general purpose of wound cleansing?

• Answer: Wound cleansing is used to remove necrotic tissue, purulent drainage, and debris from the wound area. This helps promote healing and reduces the risk of infection. Common solutions include sterile 0.9% sodium chloride (saline) or other cleansers.

Flashcard 2: Wound Cleansing Methods

• Question: What are the different methods of wound cleansing?

• Answer: Wound cleansing methods include:

  1. Passive Irrigation: Gravity-driven solution flows top-to-bottom, carrying debris away from the wound.

  2. Mechanical Cleansing: Uses gauze and a cleansing solution to scrub the wound, though excessive scrubbing can be painful and harmful.

  3. Pressurized Irrigation: Delivers solution at 8 psi through a syringe or catheter to clean the wound effectively, starting at the upper edge of the wound.

Flashcard 3: Whirlpool Tubs in Wound Care

• Question: How are whirlpool tubs used in wound care?

• Answer: Whirlpool tubs are sometimes used for wound cleansing but are less practical due to issues with access, cost, and difficulty controlling the environment. They are not always the safest or most effective option.

Flashcard 4: Considerations During Wound Cleansing

• Question: What should be considered when cleansing a wound?

• Answer: When cleansing a wound, consider:

  • Client comfort and safety: Wound care can be painful, so assess and treat pain before and after cleansing.

  • Environmental factors: Ensure the surrounding area is clean and dry, and place a clean pad beneath the wound to collect drainage.

Flashcard 5: Types of Debridement

• Question: What are the different types of wound debridement?

• Answer: Wound debridement types include:

  1. Mechanical Debridement: Achieved by wound irrigation or wet-to-dry dressings that remove nonviable tissue when the dressing is changed.

  2. Autolytic Debridement: Uses the body’s own fluids to self-digest nonviable tissue, often facilitated by specialized dressings.

  3. Chemical Debridement: Uses topical enzymes to break down dead tissue.

  4. Surgical Debridement: Involves using surgical tools like scalpels or scissors to remove dead tissue.

Flashcard 6: Wet-to-Dry Dressings and Debridement

• Question: Why are wet-to-dry dressings no longer commonly used for debridement?

• Answer: Wet-to-dry dressings are nonselective, meaning they may remove both healthy and nonviable tissue, which can cause pain and further damage. They are considered outdated due to these disadvantages.

Flashcard 7: Pressurized Irrigation for Wound Cleansing

• Question: How is pressurized irrigation used in wound cleansing?

• Answer: Pressurized irrigation uses a solution delivered at 8 psi through a syringe or catheter. The syringe is held about 1 inch above the wound, starting at the upper edge and moving downward to effectively cleanse the wound.

Here’s a breakdown of Negative Pressure Wound Therapy (NPWT), also known as Vacuum Assisted Closure (VAC), using flashcards for quick study:

Flashcard 1: Purpose of NPWT

• Question: What is the primary purpose of Negative Pressure Wound Therapy (NPWT)?

• Answer: NPWT is used to assist in wound contraction, promote debridement, and remove exudate from the wound. It helps in speeding up wound healing, reducing bacterial counts, and stimulating granulation tissueformation.

Flashcard 2: How NPWT Works

• Question: How does Negative Pressure Wound Therapy work?

• Answer: NPWT applies suction to the wound area using a porous foam or gauze dressing. The dressing is sealed with transparent adhesive tape, and the exudate is removed by negative pressure and stored in a collection container.

Flashcard 3: Benefits of NPWT

• Question: What are the benefits of using NPWT?

• Answer: NPWT helps salvage limbs, speeds up wound healing, and is cost-effective since it typically does not require surgery. It can be used across various healthcare settings, including hospitals, extended care, and home care.

Flashcard 4: Contraindications for NPWT

• Question: When should Negative Pressure Wound Therapy NOT be used?

• Answer: NPWT should not be used in:

  • Areas with skin cancer

  • Clients on anticoagulants

  • Clients with poor tissue health

  • Wounds with exposed vessels, nerves, or organs

Flashcard 5: Application of NPWT

• Question: Who can apply NPWT and how is it applied?

• Answer: A trained wound care specialist, physical therapist, or any other healthcare provider trained in NPWT can apply the therapy. The device involves placing a porous foam or gauze dressing in the wound, which is sealed with transparent adhesive tape. A vacuum unit is then used to provide negative pressure.

Flashcard 6: Safety Considerations with NPWT

• Question: What safety considerations should be taken when using NPWT?

• Answer: Caution is advised when using NPWT for clients with:

  • Decreased sensation

  • Anticoagulant therapy

  • Wounds with tracts or tunneling

Flashcard 7: How NPWT Functions

• Question: How does the NPWT device function during therapy?

• Answer: The NPWT unit creates negative pressure in the wound, cycling through on and off states to manage fluid and exudate removal. The unit typically makes a noise as it works. The therapy can be set for continuous or intermittent negative pressure depending on the needs of the wound.

Flashcard 8: Monitoring and Troubleshooting NPWT

• Question: How should an NPWT device be monitored and troubleshooted?

• Answer: The NPWT device should be regularly assessed to ensure it is maintaining the correct pressure settingsas prescribed. If troubleshooting is needed, refer to a wound care specialist, follow facility protocols, or consult the manufacturer's instructions.

Flashcard 1: Purpose of Drains in Wound Care

• Question: What are the main purposes of drains in wound care?

• Answer: Drains are used to:

  • Collect exudate

  • Measure drainage

  • Protect surrounding skin

  • Contain microorganisms

  • Reduce the frequency of wound care

Flashcard 2: Closed Drainage Systems

• Question: What is a closed drainage system, and how does it work?

• Answer: A closed drainage system uses compression and suction to remove drainage and collect it in a reservoir. It reduces the risk of infection and allows more accurate measurement of drainage. Examples include self-contained drainage systems (e.g., small bulb with suction) and portable wound suction devices (larger disc-shaped reservoirs).

Flashcard 3: Self-Contained Drainage System

• Question: How does a self-contained drainage system work?

• Answer: A self-contained system uses a small bulb attached to a plastic tube. After emptying the bulb, it is compressed to generate suction, facilitating drainage. The system requires recompression when the bulb fills or is no longer compressed.

Flashcard 4: Open Drainage Systems

• Question: What is an open drainage system, and what are its drawbacks?

• Answer: An open drainage system (e.g., Penrose drain) uses a small plastic tube that drains into an absorbent dressing. Drawbacks include:

  • Difficulty in assessing drainage amounts

  • Increased risk of infection due to the potential for microorganism transmission

Flashcard 5: Pressure Redistribution Surfaces

• Question: What is the purpose of pressure redistribution surfaces, and when should they be used?

• Answer: Pressure redistribution surfaces are used to reduce pressure on high-risk areas (e.g., occipital bone, spinous process) and help prevent pressure injuries. They should be used even if the skin is intact but the patient is at high risk for breakdown.

Flashcard 6: Types of Pressure Redistribution Surfaces

• Question: What are some types of pressure redistribution surfaces?

• Answer: Types include:

  • Nonpowered foam surfaces

  • Specialized beds (e.g., air-fluidized beds for high-stage pressure injuries)

  • Low-air-loss surfaces (overlays placed on standard mattresses for pressure redistribution and moisture management)

Flashcard 7: Therapies for Wound Healing

• Question: What are some therapies used for wound healing, especially for pressure injuries?

• Answer: Therapies include:

  • Biological dressings (e.g., collagen dressings)

  • Electrical stimulation for stage 2-4 pressure injuries to stimulate granulation and circulation

  • Negative pressure wound therapy (NPWT) for stage 3-4 pressure injuries

  • Hyperbaric oxygen therapy to stimulate cell growth for burns and necrotic infections

  • Growth factor therapy using plasma rich in platelets for fibroblast activation

  • Ultrasound therapy to reduce pain, stimulate granulation, and decrease infection

Flashcard 8: Electrical Stimulation in Wound Healing

• Question: How does electrical stimulation help in wound healing?

• Answer: Electrical stimulation stimulates granulation tissue growth, promotes blood vessel growth, and helps in the healing of chronic wounds by improving circulation and reducing pain. It is contraindicated for clients with skin cancer.

Flashcard 9: Hyperbaric Oxygen Therapy

• Question: What is hyperbaric oxygen therapy, and how does it assist wound healing?

• Answer: Hyperbaric oxygen therapy uses 100% oxygen to stimulate cell growth, improve circulation, and promote healing of necrotic infections or burns.

Flashcard 10: Ultrasound Therapy in Wound Healing

• Question: How does ultrasound therapy aid in wound healing?

• Answer: Ultrasound therapy reduces pain, stimulates granulation of the wound bed, and decreases the rate of infection by promoting circulation and cellular activity.

Flashcard 2: Edema

• Question: What is edema?

• Answer: Edema is the excessive fluid accumulation within the interstitial or intracellular spaces.

Flashcard 3: Erythema

• Question: What causes erythema in the skin?

• Answer: Erythema is the redness of the skin caused by the dilation of superficial capillaries.

Flashcard 4: Eschar

• Question: What is eschar?

• Answer: Eschar is brown, black, or tan dead tissue or crust attached to a wound.

Flashcard 5: Granulation Tissue

• Question: What is granulation tissue?

• Answer: Granulation tissue consists of minute capillaries and tissue that fill an area of destroyed tissue, indicating the progression of wound healing.

Flashcard 6: Irrigation

• Question: What does irrigation involve in wound care?

• Answer: Irrigation is the process of washing out a wound, body cavity, or space with fluid to cleanse it.

Flashcard 7: Laceration

• Question: What is a laceration?

• Answer: A laceration is a wound with jagged edges.

Flashcard 8: Necrosis

• Question: What does necrosis refer to?

• Answer: Necrosis is the death of cells, tissues, or organs due to a lack of blood supply, disease, or injury.

Flashcard 9: Pressure Ulcer

• Question: What is a pressure ulcer?

• Answer: A pressure ulcer is an impaired skin integrity and/or formation of a wound over a bony prominencecaused by prolonged pressure.

Flashcard 10: Purulent Drainage

• Question: What is purulent drainage?

• Answer: Purulent drainage consists of or contains pus.

Flashcard 11: Pus

• Question: What is pus?

• Answer: Pus is a yellowish liquid that is a product of inflammation or infection.

Flashcard 12: Serous Drainage

• Question: What is serous drainage?

• Answer: Serous drainage is thin, watery drainage from a wound.

Flashcard 13: Skin Maceration

• Question: What is skin maceration?

• Answer: Skin maceration is the softening of skin from prolonged contact with moisture such as fluid, water, perspiration, urine, feces, or drainage.

Flashcard 14: Slough

• Question: What is slough in wound care?

• Answer: Slough is white or yellow, soft, stringy dead tissue attached to the wound bed.

Flashcard 15: Wound Debridement

• Question: What is wound debridement?

• Answer: Wound debridement is the removal of necrotic tissue or foreign material from a wound.

Flashcard 16: Wound Dehiscence

• Question: What is wound dehiscence?

• Answer: Wound dehiscence is the disruption of a wound with partial or total separation of wound layers.

Flashcard 17: Wound Drainage

• Question: What is wound drainage?

• Answer: Wound drainage refers to the seepage or withdrawal of fluids from a wound.

Flashcard 18: Wound Exudate

• Question: What is wound exudate?

• Answer: Wound exudate is the fluid or semisolid material slowly released by blood vessels or tissues due to inflammation or injury.