Wound Certification Exam: Comprehensive Guide for Healthcare Professionals, Exams of Nursing

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WOUND CERTIFICATION EXAM QUESTIONS AND

ANSWERS

List the principles of surgical asepsis and explain the rationale for each principle. - answers- - sterile object remains sterile only when touched by another sterile object

• place only sterile objects on sterile field
• sterile object or field out of range of vision or an object held below a person's waist is contaminated
• sterile object becomes contaminated by prolonged exposure to air
• a sterile object or field becomes contaminated by capillary action when a sterile surface comes in contact w/ a wet contaminated surface
• b/c fluid flows in direction of gravity, sterile object becomes contaminated if gravity causes a contaminated liquid to flow over surface of an object (keep wet hands up above elbows, dry from fingers to elbows)
• the edges of a sterile field or container are contaminated (1-inch border) Partial-thickness wound - answers- wounds that heal by primary intention and shallow wounds that only involve loss of epidermis/dermis Heal by resurfacing of wound with new epidermal cells Partial-thickness wound repair - answers- inflammatory response-[erythema/edema inc wbc to site]. Usually subsides in <24 hrs Epidermal repair-[epidermal cells migrate across wound]. Moist env-heal in ~4days, dry env-heal in 7 days Dermal repair-[epidermis thickens and anchors to cells]. Resumes normal fxn. Pink, dry, and fragile skin. Occurs concurrently w/ epidermal repair Full-thickness wound - answers- involve tissue loss and extend to at least Sub q layer. Can be acute (surgical wound) or chronic (pressure ulcer) Can be healed by primary or secondary intention Full-thickness wound repair - answers- hemostasis-[controls bleeding]. Platelets cause coag and vasocontriction, and break down and release growth factors (gf initiate entire

wound healing process). Does not occur in wounds healing by secondary intention! (comprimises repair process) Inflammation-[establish clean wound bed & bacterial balance]. Brings wbc to area, cleans site, releases addt'l gf. Lasts 3 days in acute wounds, >3 days in chronic wound (pressure ulcer) Proliferation-[prod. Of new tissue, epithelialization, contraction]. W/ primary intention new capillary networks form to provide o2 and nutrients and synthesis of collagen. Wound contracts as collagen fibers increase in size. Epithelial cells migrate and cover defect (occurs faster in moist env!!!!). W/ pressure ulcer, takes longer. As granulation tissue fills defect, contraction and epithelialization can occur. Contraction is more important in secondary wounds b/c it reduces amnt of granulation tissue needed to fill defect!!! Remodeling-[reorganizes collagen to produce more elastic, stronger collagen for scar tissue]. Lasts up to 1 year. Tensile strength never more than 80% or non-damaged tissue. Remodeling phase is same for primary and secondary intention wounds Wound drainage=serous, sanguineous, serosanguineous, purulent. If strong odor=infection likely Common complications of wound healing - answers- hemorrhage

• internal or external Demonstrate correct examination of wounds and Wound drainage - answers- assessment
• anatomical location
• extent of tissue involvement
• size
• tissue type
• % of wound tissue
• volume and color of wound exudate
• condition of surrounding skin Infection
• contaminated/traumatic wound infection develops within 2 to 3 days
• surgical wound infection develops within 4 to 5 days Dehiscence
• separation above the fascia Evisceration
• separation below the fascia and visceral organs protrude

Factors that impair normal wound healing - answers- do not massage reddened areas! May further damage tissue capillaries Certain medical conditions (diabetes). Monitor blood glucose (bg) levels!!! Certain meds (steroids) Age, nutrition, immunosuppression, obesity, the extent of the wound, tissue perfusion, smoking, diabetes mellitus, radiation, and wound stress Dryness-new epithelial cells migrate across a moist surface. If dry, cells needs to find moisture below surface Risk factors for pressure ulcer development and nursing interventions to reduce ulcer development - answers- shear-keep hob <30 degree angle. Reposition frequency is determined by tissue tolerance, lvl of activity, and mobility. Std=every 1-2 hrs for bed bound, every 1 hr for chair. Use support surfaces to redistribute wt Friction-minimal layers of bed linens between pt and the surface. Keep heels off bed. Teach pt's to reposition wt every 15 min. Use assisitive devices when transferring or turning pt. Moisture-use an incontinence cleanser and moisture barrier cream, toileting schedule, fecal incontinence collector or condom cath, use underpads or diapers that wick moisture away from skin rather than trap it Nutrition-nutrition assessment, ensure adequate intake of protein, fat, and carbs, consult rd, ensure adequate fluid intake Infection- Age-thin skin increases What intervention to take for someone with low braden score - answers- score of < for hospitalized pt or <18 for older adult=high risk of skin breakdown Topical skin care-keep skin clean, dry. Apply moisture as needed, assess daily Positioning-reposition bed bound pt every 2-4 hrs if on pressure-reducing mattress, every 1-2 hrs for regular mattress, or every hour if in chair and can't reposiiton self every 15 min. If in lateral position keep at 30 degree angle. Keep hob <30 degrees. Keep heels off bed or use heel protector. Support surfaces-maximize contact of body w/ surface of bed/chair to redistribute wt over a lg area. Reduces shear/friction/moisture. Make sure there's minimal layers of bed linens between pt and support surface. Still need to reposition pt! Reevaluate often.

Nutrition-fundemental for normal cell activity and tissue repair/regeneration. Do nutritional assessment, consult w/ rd if necessary. Req. Adequate intake of pro, fat, and cho. Protein esp. Important b/c low pro lvls cause hypoalbuminenia (causes extracellular fluid shifts to tissues, increases edema, which changes pressure in capillary circulation and interferes with o2 and nutrient transportation. This increases pressure ulcer risk!) Factors that promote normal wound healing - answers- offload pressure Reduce friction/shear Protect from moisture Optimize nutrition Adequate hydration Reduce edema Control bg lvls Prevent/manage infection Cleanse wound Remove nonviable tissue Maintain appropriate lvl of moisture Eliminate dead space Control odor Eliminate/minimize pain Protect periwound skin Signs of wound infection - answers- redness Warmth of surrounding tissue Odor Presence of exudate Purposes of and precautions taken with applying bandages and binders - answers- 1. Inspect the skin abrasions, edema, discoloration, or exposed wound edges.

2. Cover exposed wounds or open abrasions with a sterile dressing.
3. Assess the condition of underlying dressings and change if soiled.
4. Assess the skin of underlying body parts that are distal to the dressing for signs of circulatory impairment When to use heat therapy? - answers- is best used for patients afflicted with degenerative joint disease, localized muscle strain, menstrual cramping, hemorrhoid and perianal inflammation, local abscess. When to use cold therapy? - answers- is best used for patients afflicted with a sprain, strain, fracture, muscle spasm, superficial laceration, minor burn, arthritis, after an injection, or joint trauma. See table 36-7 on page 1088 for additional information.

Physiological response to heat therapy - answers- vasodilation Reduced blood viscosity Reduced muscle tension Increased tissue metabolism Increased capillary permeability Improves blood flow to injured body part Promotes muscle relaxations and pain relief Physiological response to cold therapy - answers- vasoconstriction Local anesthesia Reduced cell metabolism Increased blood viscosity Decreased muscle tension Reduces blood flow to injured site; prevents edema Reduces inflammation and o2 needs of tissues Relieves pain Describe the differences in therapeutic effects of heat and cold and application. Demonstrate application of heat/cold therapy - answers- body responses to heat and cold

• systemic responses (heat loss or conservation mechanisms)
• local responses (stimulation of nerve endings)
• adaptive process Local effects of heat and cold
• heat: reflex vasoconstriction
• cold: reflex vasodilation Factors influencing heat and cold tolerance
• duration of application
• body part
• damage to body surface
• prior skin temperature
• body surface area
• age and physical condition Assessment for temperature tolerance
• conditions that contradict therapy
• patient sensory function
• condition of equipment Patient education and safety
• purpose, symptoms of temperature exposure, and precautions

Applying heat and cold

• health care provider's order required
• follow agency temperature policy Choice of moist or dry
• type of wound or injury
• location of the body part
• presence of drainage or inflammation
• cold moist compresses
• cold soaks
• ice bag or collar
• commercial cold packs
• warm moist compresses
• warm soaks
• sitz bath
• commercial hot packs
• hot water bottles
• electric heating pads Nursing care plan for a patient with impaired skin integrity - answers- pt-centered goals aimed at preventing/reducing impaired skin integrity or promoting wound healing. Assess all pt's for risk for skin breakdown (braden scale) and perform skin and wound assessments daily Why would we use montgomery straps and what are they - answers- to avoid repeated removal of tape from sensitive skin Each tie has a long strip-half has adhesive backing, half has cloth tie that ties across dressing. Can be untied at dressing changes. Long dressing may require 2 or more montgomery straps Stages of pressure ulcers - answers- stage 1-intact skin w/ nonblanchable redness Stage 2-partial-thickness skin loss involving epidermis, dermis, or both Stage 3-full-thickness tissue loss w/ visible fat Stage 4-full-thickness tissue loss w/ exposed bone, muscle, or tendon How nutrition helps and prevents wounds from healing - answers- it is fundamental for normal cell activity and tissue repair/regeneration, especially protein Monitor for fluid/lyt balance

Proper way a wet to dry dressing should be done - answers- - moisten gauze w/ prescribed solution

• wring out excess, apply moist/fluffed gauze or packing strip directly onto wound surface. - do not let gauze touch surrounding skin
• pack undermining and tunneling loosely
• cover w/ dry sterile gauze
• cover that w/ secondary dry dressing (abd pad, gauze, surgipad)
• tape in place, secure w/ roll gauze or montgomery straps What is the purpose of wet to dry dressings? - answers- moistened gauze increases absorptive ability of dressing to collect exudate, which prevents bacterial growth and wound drainage from coming in contact w/ intact skin Moist env. Promotes normal epidermal cell migration What will you do if the sterile item touches a none sterile item (such as dropping gauze on the floor?) - answers- use a new sterile item, that one that touches the non-sterile item is now contaminated. Do not break sterile field! Sterile-sterile What are some nursing interventions for a sprained ankle? - answers- rest Ice Compression Elevation (rice) What does the braden scale look at? What are you assessing with it? - answers- predictive tool for pressure ulcer development Sensory perception Moisture Activity level Mobility Nutrition Friction Shear Score of <16 for hospitalized pt or <18 for older adult=high risk for skin breakdown! Purpose of dressings - answers- provides a moist environment Protects from microorganisms Promotes hemostasis Eliminates dead space Absorbs drainage Immobilizes a body part Promotes thermal insulation

Gauze dressing - answers- most common, available in many shapes and sizes Does not interact w/ wound tissue, so little wound irritation Best for wounds w/ moderate drainage, deep wounds, undermining, and tunnels Apply either moist or dry Purpose of dry dressing - answers- promotes healing by allowing wound to heal by primary intention and absorbing minimal oozing of wound drainage Purpose of moist dressing - answers- promotes excessive wound absorption (like a sponge). Use w/ secondary intention. Change when it is saturated or if it begins to dry out. always cover moist dressing w/ dry secondary dressing Transparent film dressing - answers- clear adhesive sheets. Adhesive does not stick to wound b/c of the moisture and traps moisture over wound bed-provides moist env! Impermeable to fluid but permeable to o2. Used as primary dressing on wounds w/ minimal tissue loss and very little wound drainage Hydrocolloid dressing - answers- gelling agents, have adhesive wound surface Occlusive, protect wound from surface contaminants, and can be left on wound for several days. Some gel remains when removed, it maintains moist env. To support healing!!! Washes away during cleansing Hydrogel dressing - answers- available in sheets or as a gel in a tube Indicated for wounds that require moisture (granulation or necrosis) Maintains moist wound env. Needed for healing!!! Facilitates debridement by softening necrotic tissue!!!

Negative-pressure wound therapy (npwt) - answers- - evacuates fluids

• stimulates granulation tissue formation
• reduces bacteria
• maintains a moist wound environment What are 3 types of drains? - answers- jp (jackson-pratt) Hemovac Penrose Know the proper steps for a dressing change and what to assess - answers- preparation=
• know the type of dressing and any underlying drains used.
• gather needed supplies.
• use aseptic technique.
• explain the procedure to the patient before beginning. Home care=
• provide patient education.
• provide opportunities for practice before discharge. Securing dressings=
• tape
• montgomery ties
• dressings and cloth binders Comfort measures=
• "time outs"
• scheduling
• soaking
• supporting wound
• low or nonadhesive dressings
• pre-medicate 30-60 min prior if needed!!!!!! How are wounds cleansed? - answers- removes surface bacteria and prevents invasion of healthy tissue Use normal saline, not betadine, h2o2, or acetic acid, to irrigate a clean, granular wound (they're toxic to fibroblasts so will impair wound healing)

1. Clean from least contaminated to most contaminated 2.light friction when applying antiseptics locally

3. When irrigating, allow solution to flow from least contaminated to most contaminated How are wounds irrigated? - answers- done to cleanse wounds of exudate and debris. Use an irrigating syringe to flush area with a constant flow of solution. Useful for cleaning open, deep wounds or sensative or inaccessible body parts. Administer solution (normal saline usually) at body temp When irrigating a clean wound, use sterile technique and and irrigation system w/ a safe lvl of pressure!!! First aid for wounds - answers- hemostasis-apply direct pressure to wound w/ a sterile or clean dressing, elevate!! Do not remove penetrating objects from puncture wounds! Cleansing-gently removes contaminents, vigorous causes bleeding/further injury. Abrasions, minor lac, small punctures=rinse w/ running water, gently cleanse w/ mild soap and rinse w/ water. Lac bleeding profusely=focus on hemostasis Protection-apply sterile or clean dressing and immobilize body part Abrasion - answers- loss of the dermis Usually superficial w/ weeping (plasma leakage from broken capillaries) Binders - answers- dressings made of large pieces of material to fit a specific body part. Reduces stress on a wound! Blanchable hyperemia - answers- area that appears red and warm blanches (turns lighter in color with palation) Compress - answers- soft pad of gauze or cloth used to apply heat, cold, or meds to surface of a body part Debride - answers- remove damaged and dead tissue from a wound. Dehiscence - answers- surgical complication where there is separation or bursting open of a surgical wound Ecchymosis - answers- bruising Eschar - answers- thick, leather dead tissue that may be loose or adhered to the skin; often black or brown

Evisceration - answers- protrusion of visceral organs through a surgical wound. Friction - answers- surface damage caused by skin rubbing against another surface that often results in an abrasion Granulation tissue - answers- red, moist tissue consisting of blood vessels and connective tissue Covers wound base in wounds healing by secondary intention Tertiary intention - answers- "delayed primary closure" Deep-tissue layers heal thru primary, sub q and skin layers left open to heal thru secondary Hematoma - answers- a mass of blood in the soft tissues beneath the skin. Hemostasis - answers- stoppage of bleeding Induration - answers- hardening of tissue caused by edema or inflammation Palpate tissues next to observed area to assess for it Laceration - answers- wound or injury with jagged, irregular edges. Damage to dermis and epidermis Heals by secondary intention Maceration - answers- softening or dissolution of tissue after lengthy exposure to fluid Nonblanchable hyperemia - answers- redness that persists after palpation and indicated tissue damage Pressure ulcer - answers- impaired skin integrity resulting from pressure. Localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear Primary intention - answers- wound healing with little or no tissue loss (like surgical incision) Edges approximate Risk for infection minimal

Reactive hyperemia - answers- redness of the skin resulting from dilation of the superficial capillaries Blanches Secondary intention - answers- healing where skin edges do not approximate because of extensive tissue loss Healing occurs gradually Ex=pressure ulcer Shear - answers- force exerted against skin while skin remains stationary and bony structures move Sitz bath - answers- bath in which only pelvic area is immersed in warm fluid Tissue ischemia - answers- decreased blood flow to tissue Usually results in tissue death and occurs when capillary blood flow is obstructed