ADVANCED WOUND CARE EXAM
QUESTIONS AND ANSWERS
What is a wound - ans- km km km km km
A wound can be defined as any disruption to the integrity of the skin, mucous membrane or or
km km km km km km km km km km km km km km km km km
gan tissue. A wound can be caused by trauma, surgery, chemical or thermal damage or disea
km km km km km km km km km km km km km km km
se. It can be acute or chronic
km km km km km km
Repair stage of wound healing - ans-inflammation, reconstruction and maturation
km km km km km km km km km
reconstruction phase of wound healing - ans- km km km km km km
Granulation: macrophages will continue to clean up the wound and stimulate the fibroblasts t km km km km km km km km km km km km km
o create connective tissue. A red collage type tissue which eventually becomes scar tissue. T
km km km km km km km km km km km km km km
his is healing and pink tissue
km km km km km
Contraction: the body is trying to make the wound smaller and the wound edges are being dra km km km km km km km km km km km km km km km km
wn together km
Epitheliasation: where the new skin is growing across the wound km km km km km km km km km
Primary intention healing - ans- km km km km
Closure of surgical or traumatic wound where edges held in close apposition by sutures, stapl
km km km km km km km km km km km km km km
es, tape or glue. Minimal tissue loss or scarring
km km km km km km km km
Delayed primary intention healing - ans- km km km km km
Wound kept open for intensive cleaning. Closed when no signs of infection or foreign bodies.
km km km km km km km km km km km km km km
Secondary intention healing - ans- km km km km
Too much tissue loss and you cannot pull the edges together. The rapid phase will occur and
km km km km km km km km km km km km km km km km km
will take longer and more scarring. Chronic and longer term wounds
km km km km km km km km km km
Tissue loss. Wound healing delayed. Occurs by granulation, contraction and epitheliasation.
km km km km km km km km km km km
Greater scarring km
Acute wound - ans- km km km
a wound with an aetiology that occurs suddenly, either with or without intention, but then heal
km km km km km km km km km km km km km km km
s in a timely manner. Usually within 4-
km km km km km km km
12 weeks depending on the size, depth and extent of damage to the epidermis and dermis lay
km km km km km km km km km km km km km km km km
er of the skin
km km km
Chronic wound - ans- km km km
a wound that has slow progression through the healing phases, or shows delayed, interrupte
km km km km km km km km km km km km km
d or stalled healing due to instructing and extrinsic factors that impact on the individual and th
km km km km km km km km km km km km km km km km
eir wound. Often complicated by underlying intrinsic factors.
km km km km km km km
Hypergrannulation - ans- km km
Granulation which has gone on too long. Typically granulation should stop when the wound fil
km km km km km km km km km km km km km km
ls the cavity, hypergrannulation occurs when it goes beyond the wound bed. Granulation tiss
km km km km km km km km km km km km km
ue beyond the wound surface which interferes with epitheliasation
km km km km km km km km
Contracture - ans- km km
Where there is excess hydroblast activity. Scar tissue over contracts, cosmetic and functional
km km km km km km km km km km km km k
deformity. Helped by splints, exercises, grafts, pressure garments and incision location
m km km km km km km km km km km
,Hypertrophic scarring - ans- km km km
Still within the original boundaries of the wound. Too much collagen in the healed wound, lea
km km km km km km km km km km km km km km km
ving it red, raised, firm, itchy scar within the boundary of the wound.
km km km km km km km km km km km km
Respond to compression and aid remodelling. The theory is it encouraged a more orderly ma
km km km km km km km km km km km km km km
turation of the collagen fibres, decreases oedema, decrease blood flow > hypoxia : fibroblast
km km km km km km km km km km km km km km
deformity
Keloid scarring - ans- km km km
Hypertrophic scarring beyond the boundary of the original wound. Fibrous growth from abnorkm km km km km km km km km km km km
mal connective tissues response > tumours scars extending beyond boundary of original wou
km km km km km km km km km km km km
nd, may become malignant.
km km km
Difficult to resolve. Surgical excision, corticosteroid infection, compression, radiation.
km km km km km km km km
Can be more common in people with a darker complexion or genetic history
km km km km km km km km km km km km
Wound infection - ans-Wound infection can be defined as a
km km km km km km km km km
multiplication of pathogens that overwhelm km km km km
host defences, resulting in disruption of
km km km km km
healing and damage to tissues. km km km km
Wound infection can result in local and km km km km km km
systemic host responses km km
Biofilm - ans- km km
A biofilm can be described as microorganisms embedded in a thick, slimy barrier of sugars an
km km km km km km km km km km km km km km km
d proteins. The biofilm barrier protects the microorganisms from external threats.
km km km km km km km km km km
Role of antibiotics - ans-All wounds are colonised with microbes
km km km km km km km km km
Not all are "infected"
km km km
Antibiotics are only indicated for wounds that are clinically infected km km km km km km km km km
No evidence prophylaxis has a role in preventing infection
km km km km km km km km
Local and systemic signs of infection may warrant the use of systemic antibiotics
km km km km km km km km km km km km
Antimicrobial stewardship - ans- km km km
Antimicrobial stewardship (AMS) is defined as an ongoing effort by a health service organisat km km km km km km km km km km km km km
ion to optimise antimicrobial use among patients 'to improve patient outcomes, ensure cost-
km km km km km km km km km km km km
effective therapy and reduce adverse sequelae of antimicrobial use (including antimicrobial r
km km km km km km km km km km km km
esistance).
A - wound assessment - ans-Assess the patient, wellbeing and wound.
km km km km km km km km km km
Patient, social situation, pmx, medications, allergies, the wound/location/duration/acute/
km km km km km km km
chronic/pain/measurements ect km
B - wound assessment - ans-Bring in the multi-disciplinary team
km km km km km km km km km
Dietician, nurse practitioner, wound care nurse, physiotherapist, occupational therapist, medi
km km km km km km km km km
cal staff, social worker, pharmacist, podiatrist ect.
km km km km km km
C - wound assessment - ans-control and treat barriers to healing
km km km km km km km km km km
medications
comorbidities
pain
the healing envrionment
km km
D - wound assessment - ans-Decide on most appropriate wound treatment
km km km km km km km km km km
, Short term goals: Time frame (up to approx 14 days) e.g. haemostasis, reduced pain, manag
km km km km km km km km km km km km km km
e infection, achieve moisture balance, commence granulation, commence debridement etc
km km km km km km km km km
Long term goals: Time frame (1 month? 3 months? -
km km km km km km km km km
depends on wound) e.g. no infection, wound 25% / 50% /
km km km km km km km km km km km
completely healed, function restored etc.
km km km km km
Describe a suggested wound management plan (summarising information from TIME and dr
km km km km km km km km km km km
essing plan) km
E - wound assessment - ans-
km km km km km
Explain how you will assess the treatment plan and if it has worked
km km km km km km km km km km km km
T - wound assessment - ans-Tissue viability
km km km km km km
- describe the wound bed and the surrounding skin, is it viable
km km km km km km km km km km km
I - wound assessment - ans-Inflammation
km km km km km
- None
km
- Normal
km
- Abnormal, unexpected time period
km km km km
- Abnormal, unexpected acute inflammation
km km km km
- Abnormal chronic inflammatory disease
km km km km
Infection
- Cellulitis
km
- Puskm
- Abscess
km
- Subtle signs
km km
- Delayed dealing
km km
- Erythema
km
- Haemopurulent exudate
km km
- Malodour
km
- Unexpected pain or tenderness
km km km km
M - wound assessment - ans-moisture
km km km km km
- Moisture balance of the wound and surrounding skin
km km km km km km km km
- Dry? Macerated? Exudate - TACO
km km km km km
- Serous - clear fluid, no blood, no pus
km km km km km km km km
- Haemoserous - slight blood stained serous fluid
km km km km km km km
- Sanguineous - bright red, frank blood
km km km km km km
- Purulent - containing pus (thick, cloudy, yellow)
km km km km km km km
E - wound assessment (TIME) - ans-- Advancing
km km km km km km km
- Able to be approximated
km km km km
- Colour
km
- Thickness
km
- Raised
km
- Rolled edges
km km
Classification of EBP - ans-the conscientious, explicit and judicious use of km km km km km km km km km km
current best evidence in making decisions about km km km km km km
care of individuals..It means integrating individual
km km km km km
clinical expertise with the best available external
km km km km km km
clinical evidence from systematic research" km km km km
QUESTIONS AND ANSWERS
What is a wound - ans- km km km km km
A wound can be defined as any disruption to the integrity of the skin, mucous membrane or or
km km km km km km km km km km km km km km km km km
gan tissue. A wound can be caused by trauma, surgery, chemical or thermal damage or disea
km km km km km km km km km km km km km km km
se. It can be acute or chronic
km km km km km km
Repair stage of wound healing - ans-inflammation, reconstruction and maturation
km km km km km km km km km
reconstruction phase of wound healing - ans- km km km km km km
Granulation: macrophages will continue to clean up the wound and stimulate the fibroblasts t km km km km km km km km km km km km km
o create connective tissue. A red collage type tissue which eventually becomes scar tissue. T
km km km km km km km km km km km km km km
his is healing and pink tissue
km km km km km
Contraction: the body is trying to make the wound smaller and the wound edges are being dra km km km km km km km km km km km km km km km km
wn together km
Epitheliasation: where the new skin is growing across the wound km km km km km km km km km
Primary intention healing - ans- km km km km
Closure of surgical or traumatic wound where edges held in close apposition by sutures, stapl
km km km km km km km km km km km km km km
es, tape or glue. Minimal tissue loss or scarring
km km km km km km km km
Delayed primary intention healing - ans- km km km km km
Wound kept open for intensive cleaning. Closed when no signs of infection or foreign bodies.
km km km km km km km km km km km km km km
Secondary intention healing - ans- km km km km
Too much tissue loss and you cannot pull the edges together. The rapid phase will occur and
km km km km km km km km km km km km km km km km km
will take longer and more scarring. Chronic and longer term wounds
km km km km km km km km km km
Tissue loss. Wound healing delayed. Occurs by granulation, contraction and epitheliasation.
km km km km km km km km km km km
Greater scarring km
Acute wound - ans- km km km
a wound with an aetiology that occurs suddenly, either with or without intention, but then heal
km km km km km km km km km km km km km km km
s in a timely manner. Usually within 4-
km km km km km km km
12 weeks depending on the size, depth and extent of damage to the epidermis and dermis lay
km km km km km km km km km km km km km km km km
er of the skin
km km km
Chronic wound - ans- km km km
a wound that has slow progression through the healing phases, or shows delayed, interrupte
km km km km km km km km km km km km km
d or stalled healing due to instructing and extrinsic factors that impact on the individual and th
km km km km km km km km km km km km km km km km
eir wound. Often complicated by underlying intrinsic factors.
km km km km km km km
Hypergrannulation - ans- km km
Granulation which has gone on too long. Typically granulation should stop when the wound fil
km km km km km km km km km km km km km km
ls the cavity, hypergrannulation occurs when it goes beyond the wound bed. Granulation tiss
km km km km km km km km km km km km km
ue beyond the wound surface which interferes with epitheliasation
km km km km km km km km
Contracture - ans- km km
Where there is excess hydroblast activity. Scar tissue over contracts, cosmetic and functional
km km km km km km km km km km km km k
deformity. Helped by splints, exercises, grafts, pressure garments and incision location
m km km km km km km km km km km
,Hypertrophic scarring - ans- km km km
Still within the original boundaries of the wound. Too much collagen in the healed wound, lea
km km km km km km km km km km km km km km km
ving it red, raised, firm, itchy scar within the boundary of the wound.
km km km km km km km km km km km km
Respond to compression and aid remodelling. The theory is it encouraged a more orderly ma
km km km km km km km km km km km km km km
turation of the collagen fibres, decreases oedema, decrease blood flow > hypoxia : fibroblast
km km km km km km km km km km km km km km
deformity
Keloid scarring - ans- km km km
Hypertrophic scarring beyond the boundary of the original wound. Fibrous growth from abnorkm km km km km km km km km km km km
mal connective tissues response > tumours scars extending beyond boundary of original wou
km km km km km km km km km km km km
nd, may become malignant.
km km km
Difficult to resolve. Surgical excision, corticosteroid infection, compression, radiation.
km km km km km km km km
Can be more common in people with a darker complexion or genetic history
km km km km km km km km km km km km
Wound infection - ans-Wound infection can be defined as a
km km km km km km km km km
multiplication of pathogens that overwhelm km km km km
host defences, resulting in disruption of
km km km km km
healing and damage to tissues. km km km km
Wound infection can result in local and km km km km km km
systemic host responses km km
Biofilm - ans- km km
A biofilm can be described as microorganisms embedded in a thick, slimy barrier of sugars an
km km km km km km km km km km km km km km km
d proteins. The biofilm barrier protects the microorganisms from external threats.
km km km km km km km km km km
Role of antibiotics - ans-All wounds are colonised with microbes
km km km km km km km km km
Not all are "infected"
km km km
Antibiotics are only indicated for wounds that are clinically infected km km km km km km km km km
No evidence prophylaxis has a role in preventing infection
km km km km km km km km
Local and systemic signs of infection may warrant the use of systemic antibiotics
km km km km km km km km km km km km
Antimicrobial stewardship - ans- km km km
Antimicrobial stewardship (AMS) is defined as an ongoing effort by a health service organisat km km km km km km km km km km km km km
ion to optimise antimicrobial use among patients 'to improve patient outcomes, ensure cost-
km km km km km km km km km km km km
effective therapy and reduce adverse sequelae of antimicrobial use (including antimicrobial r
km km km km km km km km km km km km
esistance).
A - wound assessment - ans-Assess the patient, wellbeing and wound.
km km km km km km km km km km
Patient, social situation, pmx, medications, allergies, the wound/location/duration/acute/
km km km km km km km
chronic/pain/measurements ect km
B - wound assessment - ans-Bring in the multi-disciplinary team
km km km km km km km km km
Dietician, nurse practitioner, wound care nurse, physiotherapist, occupational therapist, medi
km km km km km km km km km
cal staff, social worker, pharmacist, podiatrist ect.
km km km km km km
C - wound assessment - ans-control and treat barriers to healing
km km km km km km km km km km
medications
comorbidities
pain
the healing envrionment
km km
D - wound assessment - ans-Decide on most appropriate wound treatment
km km km km km km km km km km
, Short term goals: Time frame (up to approx 14 days) e.g. haemostasis, reduced pain, manag
km km km km km km km km km km km km km km
e infection, achieve moisture balance, commence granulation, commence debridement etc
km km km km km km km km km
Long term goals: Time frame (1 month? 3 months? -
km km km km km km km km km
depends on wound) e.g. no infection, wound 25% / 50% /
km km km km km km km km km km km
completely healed, function restored etc.
km km km km km
Describe a suggested wound management plan (summarising information from TIME and dr
km km km km km km km km km km km
essing plan) km
E - wound assessment - ans-
km km km km km
Explain how you will assess the treatment plan and if it has worked
km km km km km km km km km km km km
T - wound assessment - ans-Tissue viability
km km km km km km
- describe the wound bed and the surrounding skin, is it viable
km km km km km km km km km km km
I - wound assessment - ans-Inflammation
km km km km km
- None
km
- Normal
km
- Abnormal, unexpected time period
km km km km
- Abnormal, unexpected acute inflammation
km km km km
- Abnormal chronic inflammatory disease
km km km km
Infection
- Cellulitis
km
- Puskm
- Abscess
km
- Subtle signs
km km
- Delayed dealing
km km
- Erythema
km
- Haemopurulent exudate
km km
- Malodour
km
- Unexpected pain or tenderness
km km km km
M - wound assessment - ans-moisture
km km km km km
- Moisture balance of the wound and surrounding skin
km km km km km km km km
- Dry? Macerated? Exudate - TACO
km km km km km
- Serous - clear fluid, no blood, no pus
km km km km km km km km
- Haemoserous - slight blood stained serous fluid
km km km km km km km
- Sanguineous - bright red, frank blood
km km km km km km
- Purulent - containing pus (thick, cloudy, yellow)
km km km km km km km
E - wound assessment (TIME) - ans-- Advancing
km km km km km km km
- Able to be approximated
km km km km
- Colour
km
- Thickness
km
- Raised
km
- Rolled edges
km km
Classification of EBP - ans-the conscientious, explicit and judicious use of km km km km km km km km km km
current best evidence in making decisions about km km km km km km
care of individuals..It means integrating individual
km km km km km
clinical expertise with the best available external
km km km km km km
clinical evidence from systematic research" km km km km
