Download INTEG EXAM 2 COMPREHENSIVE STUDY GUIDE 2026 and more Exams Histology in PDF only on Docsity!
INTEG EXAM 2 COMPREHENSIVE STUDY GUIDE
โ what is important to look at when cart reviewing? Answer: co-morbidities, medications, allergies (important for dressing choice), lab values, imaging, and if the person uses alcohol/tobacco/drugs โ what are the big co-morbidies to look for with wound care? why? Answer: DM, HT, and CAD because they take longer to heal โ what is important to do prior to seeing a patient? Answer: set up the treatment room, proper lighting, have all of the equipment set out on a clean field, and position the patient for the best view of the wound and use proper draping โ what is the clean technique? Answer: free from gross contamination and used according to facility policy โ when is clean technique used? Answer: wound care treatments and home dressing changes
โ what is sterile technique? Answer: absence of all organisms, including viruses and spores โ when is sterile technique used? Answer: in the OR, with organ exposure, burns, and on the immunocompromised โ how do we utilize infection control in wound care? Answer: use clean gloves, treat most contaminated ulcer last, use sterile instruments for sharp debridement, clean packaged dressings, and follow waste disposal regulations โ what are wound specific subjective history questions? Answer: when and how did the wound start? have you tried anything to help? has anything helped? pain? goals? โ what is important to take notice of with a subjective history in wound care? Answer: functional status, employment, nutritional status, management of DM (if applicable), and footwear โ what lab values do we look at?
โ what is a partial thickness wound? Answer: loss of epidermis, into dermis โ what is a full thickness wound? Answer: loss of epidermis and dermis, into subcutaneous tissue โ what are possible wound shapes? Answer: round/oval, irregular, and linear โ example of a round/oval wound? Answer: arterial, neuropathic, and pressure ulcers โ example of an irregular wound? Answer: venous โ example of a linear wound? Answer: incision โ how do we document wound size? Answer: length x width x depth (in cm) and use click terminology โ what is the best way to track wound progress?
Answer: wound size โ what are other methods to track wound size? Answer: perpendicular, tracings, and photography โ what depth do partial thickness have? Answer: less than 0.2 cm โ what depth do full thickness wounds have? Answer: >0.2 cm โ what is true of the deepest spot of the wound? Answer: it may move, making it difficult to reproduce the same measurement โ what is decreasing wound bed depth evidence of? Answer: progression through proliferative phase โ what is undermining? Answer: wound extends in more than one direction underneath the surface of the skin
โ what could a sinus contain? leading to what? Answer: could contain fluid leading to abscess โ how do you document a sinus? Answer: measure depth and also measure location by clock method โ what is a fistula? Answer: abnormal connection between 2 epithelium lined structures; sometimes created for medical purpose โ what is inappropriate with a fistula? Answer: checking depth โ how do we document a fistula? Answer: measure length, width, or measure percent of wound โ what can interfere with fistula healing? Answer: drainage โ what is granulation tissue?
Answer: new connective tissue and blood vessels that form on a surface of a wound; extracellular matrix and capillaries; pink or red tissue that we want to see โ what phase of healing do we see granulation tissue in? Answer: proliferative phase โ what is slough? Answer: necrotic, non-viable subcutaneous tissue; soft and stringy; yellow or white, can be gray โ what is slough the result of? Answer: body's autolytic process to phagocytose dead cells โ is slough painful? Answer: usually not because there is no sensation โ what is eschar? Answer: dead skin and subcutaneous tissue found in full-thickness wounds that generally covers majority of wound base; leathery and brown or black โ how do we stage a wound if eschar is present?
โ if the wound base is purple what does that mean? Answer: engorgement, edema, high levels of bacteria, trauma/pressure โ if the wound base is black or brown what does that mean? Answer: non-viable, necrotic tissues โ if the wound base is yellow what does that mean? Answer: non-viable, necrotic tissues, unhealthy tendon โ if the wound base is grey what does that mean? Answer: non-viable, necrotic tissue โ if the wound base is white what does that mean? Answer: poor blood flow or maceration or bone/fascia โ what is hyperkeratosis? Answer: over production of stratum corneum creating a callous; repetitive friction or pressure โ what is serous drainage?
Answer: clear and healthy โ what is sanguinous drainage? Answer: bloody โ what is serosanguinous drainage? Answer: pink and healthy (mixture of serous and sanguinous) โ what is purulent drainage? Answer: pus; tan or brown โ what does no drainage mean? Answer: tissues are dry โ what does scant drainage mean? Answer: tissues are moist but no measurable drainage presetn โ what does small/minimal drainage mean? Answer: wound is moist to wet and about 25% of the bandage is soaked โ what does moderate drainage mean?
Answer: 4 cm from wound margins โ what can be used to describe the periwound? Answer: quality, color, epithelial appendages (hair and nails), edema, temperature โ what is induration? Answer: hardening of skin adjacent to wound; an increase in the fibrous elements in subcutaneous tissue layer commonly associated with inflammation and marked by loss of elasticity and pliability โ when is induration commonly seen? Answer: with infection and with animal bites โ what is maceration? Answer: softening of skin after being saturated with fluid โ what are characteristics of macerated skin? Answer: white color and is easily scraped off โ how does maceration occur? Answer: either draining a lot or stayed in a wet dressing
โ what is edema? Answer: abnormal amount of fluid in interstitial or subcutaneous space โ is it common to see edema with wounds? Answer: yes but not pitting edema โ how is edema documented? Answer: circumferentially measured and use bony landmarks as reference โ what is the skin temperature of the trunk? Answer: 92-96 degrees F โ what is the skin temperature of the extremities? Answer: 75-80 degrees F โ what temperature difference side to side indicates inflammatory process? Answer: 2-3 degrees F
โ are antimicrobials indicated for local infection? Answer: yes โ what is a spreading infection? Answer: organisms are invading surrounding tissue; most signs seen in periwound โ are antimicrobials indicated for a spreading infection? Answer: yes, both systemic and topical โ what is a systemic infection? Answer: organisms have spread throughout the body; can result in sepsis, septic shock, organ failure, or death โ are antimicrobials indicated for systemic infection? Answer: yes, both systemic and topical โ what guidelines are used to gather wound specimens of pressure ulcers? Answer: AHRQ Guidelines โ what do the AHRQ guidelines state?
Answer: swab cultures should NOT be done routinely or without substantial cause to determine infection โ what does a swab culture allow for? Answer: more focused antibiotics โ what does the CDC recommend for gathering wound specimens? Answer: needle aspiration or tissue biopsy โ what is the gold standard for taking a wound specimen? Answer: wound biopsy โ what is a wound biopsy? Answer: punch biopsy device or scalpel is used to extract tissue in order to provide most accurate information regarding type and quantity of bacteria โ what are the drawbacks of a wound biopsy? Answer: invasive and painful โ what is needle aspiration?
Answer: age, co-morbidities, medications, labs, mechanical stress, lifestyle choices, non-adherence, amount of damage, infection, acute vs chronic, nutritional status, incontinence, immobility โ what is needed a lot in wound care? Answer: patient education to create buy in โ when can wound care be recommended? Answer: if Pt needs wound vacs, debridement, compression therapy, and modalities โ what is medicare criteria for wound care? Answer: treatment is necessary, improvement of the condition is expected, treatment is being provided by proper clinician, and condition will not improve or will become worse without treatment โ how frequent do Pt see wound care PT? Answer: usually twice a week โ what interventions do you put in plan of care? Answer: anything you think you may do at any point in time โ who do we commonly give referrals to?
Answer: vascular, podiatry, plastics, dietician โ what recommendations can we provide? Answer: imaging, ABIs, and compression garments โ what interventions can be used in wound care? Answer: education, dressings, positioning, equipment, debridement, compression, NPWV, modalities โ what is a big tool for wound documentation? Answer: medical photography that takes 3-D forms of the wound โ what is included in the objective? Answer: wound type, location, shape, size, bed, and edges along with drainage, odor, peri wound, and interventions โ what is included in the assessment? Answer: prioritized problem list, goals, PT diagnosis, PT prognosis, and PT impression โ what is included in the prognosis? Answer: expected outcome and factors that may affect wound healing
