WOCN WOUND EXAM 2024 WITH 100% ACCURATE SOLUTIONS, Exams of Nursing

Download WOCN WOUND EXAM 2024 WITH 100% ACCURATE SOLUTIONS and more Exams Nursing in PDF only on Docsity! WOCN WOUND EXAM 2024 WITH 100% ACCURATE SOLUTIONS Goals of wound assessment - ANSWER ☑☑1. Determine etiologic factors 2. Assess systemic factors/comorbidities 3. Assess wound to determine phase of healing 4. Determine goals of topical therapy Why does hyperglycemia affect wound healing? - ANSWER ☑☑Impairs leukocyte function and negatively impacts collagen syntehesis, development of tensile strength, epithelial resurfacing What BG parameters should be maintained for wound healing? - ANSWER ☑☑BG <180 for leukocyte function; <140 for healing A1C <7 for most, <8 if hx of severe hypoglycemia, advanced comorbidities, limited life expectancy Why is nutrition relevant to wound healing? - ANSWER ☑☑Muscle or SubQ wasting increases risk of pressure/shear damage malnourished pt unable to synthesize and cross-link collagen normally protein deficiency increases risk of infection What effect do low zinc levels have on wound healing? - ANSWER ☑☑compromise collagen synthesis/crosslinking What amino acids are essential for collagen synthesis? What is the effect of stress on these amino acids? - ANSWER ☑☑Glutamine and l-arginine Not adequately produced during times of physiologic stress What weight trend suggests nutritional deficiency? - ANSWER ☑☑Unplanned weight loss =>2.5% of usual weight in 30 days or =>10% within 180 days BMI <18.5 What serum albumin level indicates malnutrition? - ANSWER ☑☑<3.5 g/dl What serum transferrin level indicates malnutrition? - ANSWER ☑☑<100mg/dl What serum prealbumin level indicates malnutrition? - ANSWER ☑☑<19.5 What total lymphocyte count level indicates malnutrition? - ANSWER ☑☑<1500 What are s/s of nutritional deficits? - ANSWER ☑☑skin rashes, cracks in mucous membranes, edema, muscle and subQ tissue wasting, nonhealing wounds, dry/pluckable hair, dry flaky itchy skin What is the suggested caloric intake? - ANSWER ☑☑30-35 cal/kg body weight What is the suggested protein intake? - ANSWER ☑☑1.25-1.5 g/kg body weight What is the suggested fluid intake? - ANSWER ☑☑30ml per kg (unless fluid restriction indicated) How do you assess perfusion/oxygenation? - ANSWER ☑☑capillary refill, pulses, presence/absence of edema, TcpO2 levels (at least 40), color of wound bed (bright pink/red), ABI for lower extremity ulcers, systolic bp/episodes of hypotension, vasopressor administration How do you assess for immunosuppression? - ANSWER ☑☑Comorbidities/therapies such as HIV, steroid tehrapy in doses >30mg/day for >30 days, and/or chemo resulting in neutropenia; high dose NSAIDs What comorbidities compromise wound healing? - ANSWER ☑☑renal failure, liver failure, multisystem trauma, smoking, advanced age What are the layers of the skin - ANSWER ☑☑Epidermis Superfatted nonalkaline soaps for dry skin CHG reduces pathogens and sepsis Individualize bathing schedule Apply lubricants, oils, creams to clean slightly damp skin What types of products are emollients? - ANSWER ☑☑mineral oil, petrolatum, lanolin, ceramides What do emollients do? - ANSWER ☑☑penetrates stratum corneum to increase lipid component and soften Layer on skin retards water loss to rehydrate What is dimethicone? - ANSWER ☑☑Moisture barrier that retards water loss What products are humectants? - ANSWER ☑☑glycerin, urea, propylene glycol, lachydrin, alpha hydroxy acids What do humectants do? - ANSWER ☑☑Water attractants - increase strateum corneum water content Who are humectants for? - ANSWER ☑☑Only for xerosis - not for macerated and sometimes not for fragile skin Which tissue layer is most susceptible to ischemic damage? - ANSWER ☑☑Muscle/fascia layer What is a macule - ANSWER ☑☑Flat spot of color change less than 0.5cm in diameter What is a papule - ANSWER ☑☑Flat spot of color change greater than 0.5cm in diameter What is a patch? - ANSWER ☑☑Raised spot of color change less than 0.5cm in diameter What is a plaque? - ANSWER ☑☑Raised spot of color change greater than 0.5cm in diameter What is a blister? - ANSWER ☑☑Serous fluid trapped under skin less than 0.5cm in diameter What is a bulla? - ANSWER ☑☑Serous fluid trapped under skin greater than 0.5cm in diameter What is erythema? - ANSWER ☑☑Generalized redness What is denudation? - ANSWER ☑☑Loss of superficial skin layer What is crusting? - ANSWER ☑☑Scab of dried exudate of body fluid, blood, or pus What is granulation? - ANSWER ☑☑proliferating tissue made of capillary networks, collagen, and other connective substances What is slough? - ANSWER ☑☑Loose, stringy, nonviable tissue What is eschar? - ANSWER ☑☑Thick, leathery, necrotic tissue What is undermining? - ANSWER ☑☑Tissue destruction underlying intact skin along wound margins What is tunneling? - ANSWER ☑☑Area of tissue loss extending in any direction from edge of wound What is the normal water content of the skin? - ANSWER ☑☑10-15% What is friction skin damage? - ANSWER ☑☑Mechanical disruption of surface layer of skin Where does friction skin damage occur? - ANSWER ☑☑under restraints, blisters on heels, surface damage on butt What precedes friction skin loss? - ANSWER ☑☑Erythema, tenderness Who commonly gets friction skin damage? - ANSWER ☑☑fragile/macerated skin What happens with recurrent friction skin damage? - ANSWER ☑☑superficial skin loss lichenification How can you prevent friction skin damage? - ANSWER ☑☑soft bathing cloths, gentle skin care, heel elevation (not just quilted boots), protective dressings, support surface with low friction low shear cover What topical treatments can be used for friction skin damage? - ANSWER ☑☑extremity - nonadherent gauze or foam dressing + wrap Silicone-based adhesive foam dressing Strips of impregnated gauze (viscopaste) Solid glycerin-based gel (if minimal exudate) perineum - zinc oxide paste or impregnated gauze strips + optional nonadherent plastic film for bacterial barrier What are skin tears? - ANSWER ☑☑Superficial skin layers slide against each other causing disruption between skin layers What are the classifications of skin tears? - ANSWER ☑☑Type 1: no skin loss - edges reapproximated or flap covers lesion Type 2: partial skin/flap loss Type 3: total skin/flap loss How can you avoid skin tears? - ANSWER ☑☑avoid tape moisturize - supple skin protect arms with wrap (ensure no compression) pad bedrails, wheelchairs, etc non-occlusive dimethicone moisture barrier Culture if not responsive to management How do you manage periwound MASD? - ANSWER ☑☑appropriate dressings Moisture barriers where adhesion is not a problem What causes peristomal MASD? - ANSWER ☑☑exposure to effluent and perspiration How do you prevent peristomal MASD? - ANSWER ☑☑secure pouching system correctly size pouch protection of peristomal skin appropriate pouch change frequency How do you manage peristomal MASD? - ANSWER ☑☑treat denuded areas with pectin powder + alcohol free liquid barrier or hydrocolloid/foam dressing under patch What causes pressure injuries? - ANSWER ☑☑prolonged/intense pressure shear force reduced/compromised tissue tolerance Why does prolonged/intense pressure cause pressure injuries? - ANSWER ☑☑ischemia from occluded capillaries, edema and waste buildup from occluded lymph capillaries, reperfusion injury from thrombi formed during stasis, oxygen free radicals that damage vessel endothelial lining Why does shear force cause pressure injuries? - ANSWER ☑☑friction + gravity, angulation and disruption of blood vessels, irregular deep lesions What types of reduced/compromised tissue tolerance contribute to pressure injuries? - ANSWER ☑☑muscle wasting loss of subq tissue underlying vascular disease/edema/hypotension hyperthermia smoking stress ________ pressure means _________ time tolerance - ANSWER ☑☑reduced increased What do redistribution surfaces do? - ANSWER ☑☑reduce intensity of pressure What does routine repositioning do? - ANSWER ☑☑reduces time factor restores blood and lymphatic flow and interstitial fluid to compromised area What do conformable surfaces do? - ANSWER ☑☑Minimize interstitial fluid shifts and minimize degree of capillary and lymph occlusion How do you reduce shear? - ANSWER ☑☑Limit HOB elevation Gatch knees when elevated Use lift sheet Support surface/linens that reduce friction Chair positioning with feet flat on floor Wheelchair or chair cushion elevated for patients that slide out What is reactive hyperemia? - ANSWER ☑☑capillary bed occluded -> hypoxia -> vasodilation -> pressure relieved -> blood rushes into dilated vessels -> reactive hyperemia (warmth, discoloration, blanchable) -> vessels return to normal as O2 demands met -> resolves within one hour What is the inflammatory response? - ANSWER ☑☑causes stage 1 pressure ulcer, vessels remain dilated in response to vasoactive substances released from damaged cells, tissue should recover without frank ulceration if all pressure and shear is relieved Deep tissue injury - ANSWER ☑☑Intact or non-intact skin with localized area of persistent non- blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister May be indurated or fluctuant Frequently progresses to deep ulcer even if cared for Visible signs may not occur for up to 4 days post-injury What are signs of impending deep tissue injury breakdown? - ANSWER ☑☑pain, temperature change, change in skin color, change in tissue turgor, failure to blanch How do you manage deep tissue injuries? - ANSWER ☑☑pressure redistribution and reduction of shear no debridement until clear necrotic tissue What are the braden scale score categories? - ANSWER ☑☑9 or below - very high risk 10-12 high risk 13-14 moderate risk 15-18 at risk What braden scale scores must you address? - ANSWER ☑☑Any 2 or below What are the braden scale categories? - ANSWER ☑☑Sensory perception Moisture Activity Mobility Nutrition Friction and Shear How do you rank in the braden scale category sensory perception? - ANSWER ☑☑1 - limited ability to feel pain over most of body What is low air loss? - ANSWER ☑☑low flow of air against the patient's skin designed to control skin heat and humidity What is support surface active therapy? - ANSWER ☑☑powered surface with air chambers that are alternately inflated and deflated according to defined cycle and not in response to patient's weight What is support surface reactive therapy? - ANSWER ☑☑surfaces that react to patient's weight by creating comfortable surface (foam, gel, water bed, air, sheepskin) no change in pressure points What are the phases of partial thickness wound repair? - ANSWER ☑☑1. inflammatory response 2. epithelial cell proliferation and migration 3. reestablishment of normal skin layers and skin thickness What happens in the partial thickness inflammatory response? - ANSWER ☑☑24 hours erythema, edema, serous exudate What happens in the epithelial cell proliferation and migration phase of partial thickness wound healing? - ANSWER ☑☑may begin within 8 hours Needs attachment of keratinocytes to wound bed and stimulation by growth factors How do you promote epithelial cell proliferation? - ANSWER ☑☑Clean, moist, healthy wound bed Low bacterial counts normal Blood glucose normal amount of growth factors and MMPs What occurs in epithelial cell proliferation and migration stage if there is dermal loss? - ANSWER ☑☑5 days post-injury a layer of fluid separates epidermis from dermis Blood vessels sprout Collagen synthesis begins day 9 to 15 and extends into fluid layer, new epidermis collapses around new vessels and collagen to form rete ridges What happens in the reestablishment of normal skin layers and skin thickness phase of partial thickness skin repair? - ANSWER ☑☑when migrating epithelial cells make contact, migration ceases Cells resume upward migration and differentiation When normal pigmentation is reestablished wound is healed What are the phases of full thickness wound repair? - ANSWER ☑☑1. Inflammatory phase: inflammation, hemostasis 2. Proliferative phase: epithelialization, granulation tissue formation 3. maturation/remodeling What happens in the inflammatory phase of full thickness wound repair? - ANSWER ☑☑1-4 days, control bleeding, establish clean wound bed Breakdown of necrotic tissue and phagocytosis of bacteria by neutrophils (first) and macrophages (best) What is hemostasis? - ANSWER ☑☑Initiates when blood contacts collagen, brief vasoconstriction, clotting pathways activated, platelet aggregation, fibrin clot formation (provides bacterial barrier and scaffolding) What do growth factors do in wound healing? - ANSWER ☑☑attract neutrophils, macrophages, and fibroblasts What risks are associated with a prolonged inflammatory phase? - ANSWER ☑☑risk of surgical dehiscence and hypertrophic scarring What factors affect the intensity/duration of the inflammatory phase of wound healing? - ANSWER ☑☑bacterial loads, devitalized tissue, diabetes/hyperglycemia, ischemia/hypoxia, protein/enzyme concentration What happens in epithelialization with full thickness wounds? - ANSWER ☑☑Epithelium gradually acquires normal thickness but rete pegs are not reestablished because it covers scar tissue How long should surgical incisions be covered with dry, sterile dressing and why? - ANSWER ☑☑24-48 hours because surgical incisions resurface within 2-3 days Best to leave on until no incisional gaps What happens in granulation tissue formation? - ANSWER ☑☑fills tissue defect with scar tissue ingrowth of new capillaries synthesis of collagen and proteins When should you be able to palpate healing ridge? - ANSWER ☑☑5-9 days post-op What are factors affecting neoangiogenesis? - ANSWER ☑☑O2 levels in wound bed, hyperglycemia, radiation/chemo, age What is the extracellular matrix? - ANSWER ☑☑newly formed connective tissue made by fibroblasts What is needed to build the ECM? - ANSWER ☑☑protein, calories, ascorbic acid, zinc, iron, copper, O2 Type __ collagen is converted to type ___ collagen for increased _______ _______ over time - ANSWER ☑☑type 3 type 1 tensile strength What is contraction? - ANSWER ☑☑only happens in open wounds mobilization of wound edges to reduce size of wounds What happens in the maturation/remodeling phase of full-thickness wound repair? - ANSWER ☑☑modification of scar tissue to produce mature scar, may take >1 year Lysis of established collagen fibers Syntehsis of new collagen fibers Scar fades from bright pink/red to light pink/white What dose of corticosteroids is of concern to wound healing? - ANSWER ☑☑40mg/day or more How do you manage the effects of corticosteroids on wound healing? - ANSWER ☑☑25-100k IU vitamin A on wound bed OR oral but make sure it doesn't interact What are possible causes of diarrhea in tube fed patients? - ANSWER ☑☑unrecognized impaction, sorbitol in elixir meds, c diff, reduced absorption d/t atrophy of villi on pt NP for more than 7 days, reduced absorption d/t edema of bowel wall in pt with low albumin What are interventions for tube fed patients with diarrhea? - ANSWER ☑☑If c diff and impaction ruled out u- antiperistaltic agents can be ordered fiber-based formulas routine probiotics for ppl on antibiotics review administration procedures for contamination potential Describe a stage 1 pressure injury - ANSWER ☑☑non-blanchable erythema of intact skin Describe a stage 2 pressure injury - ANSWER ☑☑partial thickness skin loss with exposed dermis wound bed viable, pink or red, moist, and may present as intact or ruptured serum-filled blister Describe a stage 3 pressure injury - ANSWER ☑☑full-thickness skin loss adipose tissue visible in ulcer and granulation tissue and epibole often present Describe a stage 4 pressure injury - ANSWER ☑☑full thickness skin and tissue loss exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer What is an unstageable pressure injury? - ANSWER ☑☑obscured full-thickness skin and tissue loss What are the key assessment parameters? - ANSWER ☑☑Location duration dimensions and depth in cm presence/absence of undermining or tunneling/sinus tracts status of wound bed (% granulating/epithelializing/slough) wound edges open/closed exudate (volume, character, odor, consistency) surrounding tissue systemic infection indicators pain How do you document location of tunneling/undermining? - ANSWER ☑☑location - use clock face document depth What are the priorities of wound management? ESP+E - ANSWER ☑☑Etiology: pressure, shear, venous insufficiency, arterial insufficiency Systemic support: nutrition, vitamins, glucose control, hydration, perfusion Principle-based topical therapy Evaluation (ongoing) When should a wound care goal be comfort? - ANSWER ☑☑limited life expectancy When should wound care goal be maintenance? - ANSWER ☑☑underlying pathology cannot be corrected patient lacks ability to heal d/t systemic problems that can't be corrected (chemo) uninfected heel or weight bearing ulcer covered with dry eschar in bed/chairbound patient When should wound care goal be healing? - ANSWER ☑☑when etiologic factors can be corrected and systemic support provided What are the principles of topical therapy? - ANSWER ☑☑DIWAMOPI Debridement Infection control Wick dead space Absorb excess exudate Maintain moist wound surface Open or excise closed wound edges Protect healing wound from infection/trauma Insulate - normothermic to reduce vasoconstriction and enhance cellular activity What is the problem with wet to dry dressings? - ANSWER ☑☑Often removes viable tissue, painful, may cause bleeding What can be used as an alternative to wet to dry dressings? - ANSWER ☑☑damp to damp pad with monofilament fibers designed for removal of hyperkeratotic skin or thin layer of slough or biofilm How do you cleanse a clean wound? - ANSWER ☑☑flush gently (no whirlpool or pulsed lavage) Use noncytotoxic solutions (saline, tap water, wound cleanser) How do you cleanse a necrotic/dirty wound? - ANSWER ☑☑Remove as much debris as possible without inoculating or damaging underlying tissue Irrigation 8/15 PSI or pulsatile lavage Saline, wound cleanser, antiseptic, hydrogen peroxide How do you cleanse an infected wound? - ANSWER ☑☑Debride necrotic tissue Pulsatile lavage systemic antibiotics for invasive infection topical treatment indicated when infection confined to wound surface What are methylene blue & crystal violet bound dressings for? - ANSWER ☑☑bacteriostatic for most organisms including MRSA and VRE Must be hydrated and remain hydrated or use hydrated type What are AMD gauze dressings used for? - ANSWER ☑☑gauze impregnated with antimicrobials, broad spectrum including yeast and fungi Manuka honey-based dressings are antibacterial depending on ___________ - ANSWER ☑☑concentration What are dialkylcarbamoyl chloride (sorbact) dressings used for? - ANSWER ☑☑Attract bacteria to hydrophobic surface and then trap bacteria within dressing What are indications for systemic antibiotic therapy? - ANSWER ☑☑Fever, cellulitis, increased WBC, osteomyelitis, surrounding erythema, induration, heat, tenderness, edema What is infection? - ANSWER ☑☑>10^5 org/ml bacterial adherence and invasion of viable tissue and a clinical host response What is critical colonization - ANSWER ☑☑<10^5org/ml and wound healing is impaired levels of reproducing bacteria on wound surface sufficient to interfere with repair What is colonization - ANSWER ☑☑<10^5 org/ml but wound healing is not impaired presence of replicating organisms that are not interfering with repair and do not provoke host response What are the s/s of osteomyelitis? - ANSWER ☑☑exposed bone within wound, wound that fails to close completely and involves a persistent deep sinus tract How do you diagnose osteomyelitis? - ANSWER ☑☑MRI How do you treat osteomyelitis? - ANSWER ☑☑long term IV or PO antibiotic therapy, hyperbaric O2 therapy, resection What is surgical debridement? - ANSWER ☑☑sterile excision in a controlled setting When is surgical debridement the best option? - ANSWER ☑☑for full thickness wounds involving bone or joint and wounds with large amount of necrotic tissue What must you do to surgically debride a patient with cellulitis? - ANSWER ☑☑treat the cellulitis first What is conservative sharp wound debridement? - ANSWER ☑☑removal of tissue at bedside with sterile instruments What is CSWD best for? - ANSWER ☑☑patients with loose avascular tissue who can't do surgical, not as fast or as thorough as surgical How do you enzymatically debride? - ANSWER ☑☑Use collagenase If wound is covered with eschar must crosshatch or apply at periphery Who is enzymatic debridement appropriate for? - ANSWER ☑☑Slow, expensive Debridement is the goal, surgical is not feasible, poor candidate for autolytic; or can use in conjunction with surgical What kind of dressing can not be used with enzymatic debridement? - ANSWER ☑☑antimicrobial What is autolytic debridement? - ANSWER ☑☑moist wound surface + moisture retentive dressings + patient with adequate WBCs = using WBCs and enzymes in wound fluid to digest necrotic tissue Who is autolytic debridement best for? - ANSWER ☑☑patient with dry eschar or wound with limited volume of avascular tissue as long as they have normal WBCs faster than enzymatic How do you accomplish autolytic debridement in a dry wound? - ANSWER ☑☑Need dressing that traps exudate or adds moisture e.g. thin film, gel layer + MR dressing **No hydrocolloids How do you accomplish autolytic debridement in a exudative wound? - ANSWER ☑☑dressing that absorbs excess exudate but maintains moist wound surface e.g. alginate, hydrocolloids, foam, damp, nonwoven gauze What is chemical debridement? - ANSWER ☑☑non-enzymatic solutions e.g. sodium hypochlorite (Dakins) Who is chemical debridement best for? - ANSWER ☑☑necrotic infected wounds, malodorous wounds How do you dress a wound for chemical debridement? - ANSWER ☑☑Change dressing about q12hr and protect surrounding skin with sealant or hydrocolloid What is hydrotherapy? - ANSWER ☑☑use of whirlpool, high pressure irrigation, or pulsatile high- pressure lavage Who is hydrotherapy best for? - ANSWER ☑☑loose slough and/or large exudate, wounds with heavy bacterial coutns What is ultrasonic debridement? - ANSWER ☑☑Use of US powered saline mist to remove slough, fibrinous, exudate, and bacteria cavitation forms bubbles that implode and destroy tissue, acoustic streaming less painful than CSD but costly What is larval therapy? - ANSWER ☑☑Use of maggots with containment dressings to debride What are the guidelines for the management of painful wounds? - ANSWER ☑☑Nonadherent dressings and strictly avoid wet to dry Which sponge is used for which situations in NPWT? - ANSWER ☑☑White - best for tunneled areas, bleeding, pain, or friable wound bed black or silver - more porous and needs nonadherent contact layer What type of suction should be used for NPWT? - ANSWER ☑☑continuous suction best option for heavy exudate, fistulas, first 48 hours any wound, or painful wounds intermittent promotes granulation tissue What is gauze-based NPWT? - ANSWER ☑☑uses damp gauze instead of foam What is disposable portable system NPWT? - ANSWER ☑☑negative pressure to shallow/superficial wounds or closed incisions peel off backing and apply dressing to wound, attach suction to front of dressing and battery and possible canister worn on patient waistband What are considerations for using NPWT? - ANSWER ☑☑expensive if seal is lost must remove everything and use moist wound healing until re-eval pain and bleeding common - careful with coagulants protect periwound with liquid skin barrier or transparent adhesive dressing, change canister when full, pt feels tied down What is the usual time frame for NPWT - ANSWER ☑☑2-4 weeks change mon/wed/fri Who is the best candidate for growth factor therapy? - ANSWER ☑☑neuropathic foot ulcers or neuropathic ulcers What are types of growth factor therapy? - ANSWER ☑☑Becaplermin gel autologel What is autologel - ANSWER ☑☑use of patient's own platelets especially useful for denervated wounds What is becaplermin gel? - ANSWER ☑☑apply to clean noninfected wound for 12 hours daily followed by moist saline gauze for 12 hours only for clean, noninfected wounds - mainly neuropathic CI for malignant wounds What are protease (MMP) inhibitors? - ANSWER ☑☑MMPs control levels of growth factors and cytokines (some proinflammatory, some anti) These agents downregulate proinflammatory MMPs Logical first step when clean wound fails to granulate for no obvious reason and characteristics of persistent inflammation (inexpensive) What are the two types of MMP inhibitors? - ANSWER ☑☑Collagen-ORC matrix products: MMPs bind to ORC instead of new connective tissue PHI (polyhydrated ionogens) ointment impregnated - metal ions inhibit MMP production What are extracellular matrix dressings? - ANSWER ☑☑Placed at base of clean wound Gradually breaks down in wound and provides scaffolding and release of factors promoting wound healing What type of wounds are appropriate for ECM dressings? - ANSWER ☑☑clean non-granulating wounds with low to moderate exudate What are types of ECM dressings? - ANSWER ☑☑Collagen OASIS: can moisten with saline if dry, appears gelatinous and yellowish but don't remove Alloderm: need to keep moist, no tensile strength Acell: don't remove, becomes caramel color gel What are skin substitutes and engineered tissue replacement? - ANSWER ☑☑Matrix dressings impregnated with living cells What are types of skin substitutes? - ANSWER ☑☑Epidermal Dermal Dermal-epidermal What are characteristics of dermal-epidermal replacements? - ANSWER ☑☑self-regenerating and can heal post-injury, get ingrowth of blood vessels Applied to clean wound bed, covered with nonadherent dressing and secured with compression or NPWT dressing to keep close contact What is Hyperbaric Oxygen therapy? - ANSWER ☑☑Breathing O2 under pressure increases amount of O2 dissolved in plasma What are types of HBOT - ANSWER ☑☑monoplace - 1 person, fire hazard, claustrophobia multiplace - uses hood What type of tissue will not benefit from HBOT? - ANSWER ☑☑gangrenous tissue - no perfusion What are the results of HBOT? - ANSWER ☑☑vasoconstriction, increased leukocyte function, increased antibiotic efficacy (cell wall penetration), collagen synthesis and neovascularization support, increased diffusion distance What are indications for HBOT - ANSWER ☑☑serious wound-related infections (kills anaerobes, ups WBCs for aerobes), necrotizing fasciitis, gas gangrene, chronic refractory osteomyelitis, nonhealing wounds d/t ischemia (compromised flaps/grafts, non-gangrenous ulcers in diabetic s/t ischemia, osteoradionecrosis What are absolute contraindications to HBOT? - ANSWER ☑☑untreated pneumothorax; bleomycin treatment history (O2 toxicity risk); current adriamycin, disulfiram, cisplatinum, sulfamylon, doxorubicin, and other chemo agents or amiodarone and phenergan; pregnancy What are precautions for HBOT? - ANSWER ☑☑eliminate all flammable products, no smoking, dressing that can be easily removed or has no fire safety issues, HBOT alters some med metabolism (e.g. insulin) What is the MOA of compression? - ANSWER ☑☑Increase interstitial tissue pressures, partially collapses superficial veins What is a therapeutic level of compression? - ANSWER ☑☑30-40 mmHg at ankle What are the types of static compression therapy? - ANSWER ☑☑Compression wraps (for ST management until controlled)- layered wraps, paste boot, stretchable bandages, farrow wrap & circ-aid, ace bandages not preferred Compression stockings - (for LT management) Are TED stockings good compression therapy? - ANSWER ☑☑No! but better than nothing What are the indications for dynamic compression therapy? - ANSWER ☑☑failed static or can't tolerate mixed arterial/venous disease What are the types of dynamic compression therapy? - ANSWER ☑☑sequential: legging applied 1-2x/day for 1-2 hours Intermittent: same but provides intermittent compression to whole leg What are contraindications to static and dynamic compression therapy? - ANSWER ☑☑static: uncompensated HF, ischemic disease of LE (ABI<0.5) Dynamic: uncompensated HF, active thrombus What is modified compression and who is it for? - ANSWER ☑☑20-30 mmHg For ABI 0.5-0.8 What is lymphedema? - ANSWER ☑☑Accumulation of protein-rich fluid in tissues caused by parasite, radical surgery, radiation, s/t chronic venous insufficiency b/c scarred lymphatics What is reversible lymphedema? - ANSWER ☑☑causes pitting edema starting at toes and foot temporarily reduced by elevation/compression What is spontaneously irreversible lymphedema? - ANSWER ☑☑non-pitting AKA "brawny" edema, rough cobblestone texture, pos stemmer sign (unable to pinch skin fold at base of 2nd toe dorsal), elevation ineffective What is lymphostatic elephantitis? - ANSWER ☑☑breakdown of elastic skin components, increase in limb size, tissue hardens, papillamatous outgrowths, ulceration, debilitating and potentially life- threatening What does lymphedema present as? - ANSWER ☑☑edema extending from toes to groin, stemmer, poor response to elevation and compression, skin and soft tissue changes How do you treat lymphedema? - ANSWER ☑☑early: nonelastic compression and elevation, pump therapy can work but can cause damage advanced: refer to treatment center for manual massage and continual use of non-elastic bandages and exercises and meticulous skin care What is the pathology of LEAD? - ANSWER ☑☑Atherosclerosis, increase in blood viscosity and coagulability leading to thrombus result in narrowed vessels and obstruction of flow, loss of vessel elasticity and fixed rate of flow What are the risk factors of LEAD? - ANSWER ☑☑smoking, DM, hyperlipidemia, HTN, age, obesity, family history of cardiovascular disease, autoimmune or inflammatory condition, elevated homocysteine levels What are the s/s of LEAD? - ANSWER ☑☑Progressive pain: intermittent with activity to nocturnal and rest pain, relieved by rest and dependency Chronic tissue ischemia: hair loss, nail ridges, thin shiny skin, pallor, ashen tone Temperature changes Elevational pallor, dependent rubor Venous filling time > 20 seconds weak/absent pulses Reduced ABI Toe-brachial index <0.64 TcPO2 <30 Diminished sensory function Delayed capillary refill Bruits in femoral or popliteal vessels How do you test elevational pallor/dependent rubor? - ANSWER ☑☑patient supine and raise leg 60 degrees for 15-60 seconds then place in dependent position and observe color How do you improve perfusion for a patient with LEAD? - ANSWER ☑☑revascularization - bypass/angioplasty Meds - aspirin, cilostazol, statis, clopidogrel, analgesics Progressive walking program after healing HBOT dynamic compression therapy What patient education is necessary for LEAD? - ANSWER ☑☑No tobacco or constriction, hydrate, neutral/dependent positioning, no trauma, low cholesterol, niacin to increase HDL-C and decrease triglycerides, professional foot and nail care, glucose control How does an arterial ulcer present? - ANSWER ☑☑toes or forefoot ulcer base and surrounding tissue pale, dry punched out appearance infection common but not always apparent (faint halo/increased pain) size: usually small and deep, necrosis common When should you debride an arterial ulcer? - ANSWER ☑☑Debridement contraindicated in dry, uninfected wounds until blood flow adequate for healing - paint with antiseptic and leave open to air Patient closes eyes, push great toe up/down/side to side and pt identifies direction How do you assess motor neuropathy? - ANSWER ☑☑inspect for deformities, altered contours, or callus formation How do you assess autonomic neuropathy? - ANSWER ☑☑observe for very dry or very damp feet How do you prevent neuropathic ulcers? - ANSWER ☑☑correctly fitting shoes; no heels, rigid soles, turned up tips, rocker bottom for MT head problems; check feet daily for increased heat after 20 minute rest and offload hot areas >4 degree difference; break in new shoes gradually; offload heels if bedbound; always wear footwear; shake out shoes; check water temperature How do you treat autonomic neuropathy? - ANSWER ☑☑pumice stone to fissures, vinegar water soaks for 10 m in 2-3x/week, light buffing, emollients but not between toes What patient education should be provided for neuropathy? - ANSWER ☑☑don't return to problem shoes, will continue to need pressure reduction, orthotist referral, protective sensation loss + deformity + ulcer history need custom extra depth shoes and insoles, lower level interventions ok when no hx of ulceration What is total contact casting? - ANSWER ☑☑Type of offloading stress evenly distributed over LE felt or foam protection + stockinette + toe protection Leave on for 3-7 days What are the advantages of total contact casting? - ANSWER ☑☑immobilizes limb, contours to foot, reduces edema with static compression, protects from further trauma, high compliance What are the limitations of total contact casting? - ANSWER ☑☑clinician proficiency, time consuming, heavy and bulky, no frequent wound care/assessments, no infection or osteomyelitis, wound wider at surface to prevent premature closure, CI for ischemia What is a removable cast walker? - ANSWER ☑☑boot with hard outer shell What are the advantages of removable cast walkers? - ANSWER ☑☑lighter weight, some will relieve edema, protects toes, one time charge for payer, removable What are the limitations of removable cast walkers? - ANSWER ☑☑Does not accommodate deformities, compliance issues, cost prohibitive What is a half-shoe? - ANSWER ☑☑sandal with elevated heel to reduce MT pressure What are the advantages of a half-shoe? - ANSWER ☑☑modifiable for foot, lightweight but stable and reusable, allows frequent wound inspection, less cumbersome What are the limitations of a half-shoe? - ANSWER ☑☑dorsal foot and toes unprotected, compliance issues, poorer healing rates, increased steps What causes a vasculitic ulcer? - ANSWER ☑☑Caused by inflammation and necrosis of blood vessels usually associated with immunologic response or drug reaction What are the systemic symptoms of vasculitic ulcers? - ANSWER ☑☑malaise, fever, joint pain, muscle aches How does a vasculitic ulcer present? - ANSWER ☑☑LE around malleoli or anterior leg pre-ulcerous petechiae, purpura, palpable nodules, ecchymosis full-thickness pale-necrotic base minimal exudate pulse normal, feet warm pain not relieved by rest or dependency good edges How do you manage vasculitic ulcers? - ANSWER ☑☑Correct causative factors, pain control and moist wound healing What is pyoderma gangrenosum? - ANSWER ☑☑Inflammatory process usually s/t other disease (IBS, RA, malignancy) sometimes stand alone How does pyoderma gangrenosum present? - ANSWER ☑☑small pustules with purplish borders defined craters through dermis extremely painful pathergy (marked worsening d/t minor trauma) How do you treat pyoderma gangrenosum? - ANSWER ☑☑systemic/topical steroids Dapsone antiinflammatories mast cell stabilizers Doxycycline pain management avoidance of trauma wound care - hydrofera blue What is basal cell carcinoma? - ANSWER ☑☑Most common malignancy What does a basal cell carcinoma look like? - ANSWER ☑☑excess granulation tissue pink or red nodules ulcerative lesions with rolled borders single or multipe How do you treat basal cell carcinoma? - ANSWER ☑☑surgical excision, radiation Phalanges - ANSWER ☑☑bones in the toes Proximal interphalangeal joints (PIP joints) - ANSWER ☑☑joints between the two most proximal toes bones Ray - ANSWER ☑☑toe bone (phalange) + the foot bone (metatarsal) to which it attaches Talus - ANSWER ☑☑ankle bone Corns - ANSWER ☑☑hyperkeratotic lesions typically found on toes composed of protective layers of dead skin cells that are compacted by repeated friction and pressure Callus - ANSWER ☑☑hyperkeratotic lesions usually found on plantar surface of foot caused by repeated friction and pressure Charcot's arthropathy - ANSWER ☑☑serious condition resulting from breakdown of foot and ankle bones and joints and resulting in loss of normal foot architectures assumes a rocker bottom configuration Fissures - ANSWER ☑☑linear cracks in the skin Hallux valgus - ANSWER ☑☑misaligned great toe joint (bunion) First joint of large metatarsal deviates outward and great toe deviates toward other toes Hammer toes/claw toes - ANSWER ☑☑deformity characterized by flexion contractures of the PIP or DIP joints common in patients with motor neuropathy Onychatrophia - ANSWER ☑☑atrophy of nails resulting in softer, thinner nails or possibly total nail loss Onychia - ANSWER ☑☑inflammation of cells in nail matrix; causes loosening of nail plate Onychocryptosis - ANSWER ☑☑ingrown nail - segment of nail plate penetrates into nail groove (sulcus) and subQ tissue Onychogryposis - ANSWER ☑☑large, deformed, hypertrophic nail resulting from longterm growth (ram's horn nail) Onychomycosis - ANSWER ☑☑fungal infection of nail; characterized by discolored, thickened, brittle nails Onychophosis - ANSWER ☑☑deformity of nail plate resulting in encurvated and involuted nails that exert pressure on nail grooves (C-shaped nails) Paronychia - ANSWER ☑☑infection of tissues around base of nail Plantar wart - ANSWER ☑☑small circular lesion caused by virus presents as small black dot surrounded by callus Tinea pedis - ANSWER ☑☑fungal infection between toes or on plantar aspect of foot may be mind (evidenced by dry skin, scaling, itching, and small blisters or fissures) or severe (large weeping blisters and deep fissures) athletes foot xerosis - ANSWER ☑☑dry skin How do you manage hypertrophic nails? - ANSWER ☑☑Dremel before trimming How do you manage onychomycosis? - ANSWER ☑☑Vick's vaporub to cuticle daily Clear nails Tea Tree oil fungoid tinctures systemic agents if sever - LT and need LFT monitor How do you manage corns/callouses? - ANSWER ☑☑paring and protection against friction, dry between toes How do you clean foot care instruments? - ANSWER ☑☑rinse with water cold disinfection with solution (cidex, wavicide) that is bactericidal, fungicidal, virucidal OR autoclave Rubber tubs to soak - rinse, dry, spray with lysol until wet, air dry What are recommendations for footwear if Intact sensation/no deformities? - ANSWER ☑☑ensure comfort before purchase measure foot check for correct fit at widest part of foot and shoe (place thumb at midpoint and press down - feel medial aspect of first MT head, ensure toes not compressed) walk in shoe What are shoe recommendations for hammertoes? - ANSWER ☑☑deep toe box without friction What are shoe recommendations for bunions? - ANSWER ☑☑leather shoes or soft conformable upper What are shoe recommendations for someone with diminished sensation and/or severe deformities? - ANSWER ☑☑pedorthist referral What is level one foot care? - ANSWER ☑☑For intact skin, normal sensation, palpable/audible pulses, normalish nails Annual assessment L: bullae with hemorrhagic foul-smelling dishwater drainage, crepitus, eschar-like skin plaques, numbness/painless ulcers (nerve destruction) What are abnormal lab values associated with necrotizing fasciitis? - ANSWER ☑☑WBC>14k-15k Na<135 What is normal WBC? - ANSWER ☑☑4500-11000 What is the treatment for necrotizing fasciitis? - ANSWER ☑☑early aggressive surgical debridement antibiotics HBOT IV immunoglobulin NPWT flaps and grafts What are bullous lesions? - ANSWER ☑☑Damage to structures that anchor cells to each other or to ECM Creates epidermal or intradermal separation and blisters Partial thickness and usually heal without scarring, post-inflammation hyperpigmentation may occur What causes bullous lesions? - ANSWER ☑☑congenital weakness or absence of anchoring fibrils, autoimmune diagnosis, allergic reactions targeting anchor fibrils How do bullous lesions present? - ANSWER ☑☑Less severe: blisters in response to minor trauma more severe: severe chronic blistering, secondary infection, scarring and contracture, muscous membrane and GI tract involvement How do you manage bullous lesions? - ANSWER ☑☑Treat underlying process Topical and systemic corticosteroids antiinflammatories immunosuppressives plasmapheresis human skin equivalents for congenital conditions support surface with low shear low friction nonadherent dressings with or without antimicrobials What is a fungating tumor? - ANSWER ☑☑Manifestation of solid tumors that invade surface tissues must monitor for infection How do you manage the necrosis/odor associated with fungating tumor? - ANSWER ☑☑Dakin's soaked gauze Topical metronidazole Odorproof pouch How do you manage the exudate associated with fungating tumor? - ANSWER ☑☑Dakin's soaked gauze, calcium alginate dressings, absorptive dressing How do you manage the bleeding associated with fungating tumor? - ANSWER ☑☑AgNO3 to control surface bleeds nonadherent dressings calcium alginate (hemostatic) severe - consult surgical How do you manage extravasation? - ANSWER ☑☑immediate d/c of infusion, intradermal admin of antidotes hyaluronidase for most phentolamine for pressors like dopamine Wound care Full thickness on dorsal hand call plastic surgery to maintain function How is CA-MRSA spread? - ANSWER ☑☑By shared sports equipment, day care, inmates, armed services, IVDU What is CA-MRSA like? - ANSWER ☑☑Can cause very severe infections or septic arthritis Can begin with minor skin abrasion How does CA-MRSA present? - ANSWER ☑☑Acutely tender, indurated, intensely erythematous lesion with common purulent center How do you prevent CA-MRSA? - ANSWER ☑☑avoid indiscriminate use of antibiotics hot showers and antimicrobial soaps if at risk clean shared equipment with hot, sudsy water dry linens in dryer liberal use of alcohol based hand sanitizer no shared razors How do you treat CA-MRSA? - ANSWER ☑☑I&D Antibiotics (bactrim, vancomycin) Secure dressings on all sides to avoid aerosolization What is a fistula? - ANSWER ☑☑abnormal communication between two organs or organ and skin surface What are precipitating factors for fistulas? - ANSWER ☑☑breakdown of surgical intestinal anastomosis d/t inadequate blood supply, suture line tension, improper suturing, adjacent foreign body, tumor or disease adjacent, hematoma or abscess formation, malnutrition, distal obstruction and resulting distention Conditions that disrupt bowel wall: crohn's, diverticulitis, radiation, trauma, malignancy, distal obstruction Colo fistula - ANSWER ☑☑colon