WOCN Wound Exam With complete
solution
Goals |of |wound |assessment |- 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? |- | Impairs |leukocyte |function |and
|negatively |impacts |collagen |syntehesis, |development |of |tensile |strength, |epithelial
|resurfacing
What |BG |parameters |should | be |maintained | for |wound |healing? | - 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? | - 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? | - compromise |collagen
|synthesis/crosslinking
What |amino |acids |are |essential |for |collagen |synthesis?
What |is |the |effect |of |stress |on |these |amino | acids? |- Glutamine |and |l-arginine
|Not |adequately |produced |during |times |of |physiologic |stress
What |weight |trend |suggests |nutritional | deficiency? |- 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? | - <3.5 |g/dl
| What |serum |transferrin |level |indicates |malnutrition? | - <100mg/dl
What |serum |prealbumin |level |indicates |malnutrition? | - <19.5
|
What |total|lymphocyte |count |level |indicates |malnutrition? | - <1500
|
What |are |s/s |of |nutritional | deficits? |- 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? |- 30-35 |cal/kg |body |weight
| What |is |the |suggested |protein |intake? |- 1.25-1.5 |g/kg |body |weight
What |is |the |suggested |fluid |intake? |- 30ml |per |kg |(unless |fluid |restriction |indicated)
How |do |you |assess |perfusion/oxygenation? |- | 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? | - 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? | - renal |failure, |liver |failure,
|multisystem |trauma, |smoking, |advanced |age
What |are |the |layers |of |the |skin |- Epidermis
|Basement |Membrane |Zone
Dermis
| Subcutaneous
|Tissue
|Muscle/Fascia/Bone
What |are |the |layers |of |the |epidermis? |- Stratum |corneum |- |keratinocytes |filled |with
|keratin
Stratum |lucidum |- |only |in |palms/soles, |thick |areas
Stratum |granulosum | - |odland |bodies |secrete|ceramides, |lipophilic
|Stratum |spinosum | - |desmosomes |(cell |to |cell |junctions)
Stratum |germinativum | - |dermal-epidermal | junction
What |is |the |Basement |Membrane |Zone? |- Dermal-epidermal |junction
What |are |the |components |of |the |dermis? |- Papillary |dermis: |papillae |interlock |with |rete
|ridges, |capillary |loops, |sensitive |to |point |pressure
Reticular |dermis: |mostly |type |1 |collagen, |vasculars, |and |lymphatics
What |structures |of |the |skin |can |regenerate? |- Epidermis |and |parts |of |the |dermis
What |structures |of |the |skin |heal |by |scar |formation? |- Epidermal |appendages,
|Subcutaneous | tissue/fascia/muscle
How |is |newborn |skin |different? |- No |scars |up |to |2nd |trimester
|30% |thinner | skin
Faster |epidermal |turnover
,How |is |premature |infant | skin |different? |- Very |thin, |increased |fluid |loss, |functional
|stratum |corneum | at |30-32 |weeks
What |problems |may |arise |with |infant | skin? |- increased |permeability, |increased |MARSI
|risk, |extravasation, |diaper |dermatitis
How |do |you |mitigate |MARSI |risk |in |infants/elderly? |- avoid |tape |or |use |hydrocolloid
|base |or |silicone |adhesive, |no |alcohol |removers |only |mineral |oil, |petroleum, |silicone
|(preferred), |and |citrus)
How |do |you |mitigate |extravasation |in |an |infant? |- Hyaluronidase
|OR
phentolamine | if |vasoconstrictor
How |do |you |mitigate |diaper |dermatitis? |- Higher |pH
Use |petroleum |base |for |mild |erythema |and |zinc |oxide |for |denuded | skin
|sever |denudation | - |carboxymethylcellulose/petrolatum/zinc | oxide | (Ilex)
What |bathing |considerations | must |you |take |for |premature |infants? |- <30 |weeks|bathe
|with |water |only |for |2 |weeks
What |are |common |issues |with |older |skin? |- Thinner, |collagen |shrinks |and |causes
|wrinkles
Rete |ridges |and |dermal |papillae |flatten |- |increased |risk |for |tears/stripping |Reduced
|sebaceous |and |sweat |glands |- |dry |skin
Erratic/decreased |melanin | production
|Decreased |sensation |- |increased |trauma |risk
Loss |of |SubQ |tissue |- |increased |shear |and |decreased |insulation
|Increased |malignant | lesions |- |refer |to |derm
Reduced |blood |flow, |increased |epidermal |turnover | - |slow |healing
|Increased |senescense
Maybe|increased |inflammatory |mediators, |decreased |inhibitors
|Increased |capillary |fragility |(bruises)
What |strategies |keep |skin |healthy? | - pH |balanced |cleaners |- |no |alkaline |soaps
|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? |- mineral | oil, |petrolatum, |lanolin, | ceramides
What |do |emollients |do? |- penetrates |stratum |corneum |to |increase |lipid |component |and
|soften
Layer |on |skin |retards |water |loss |to|rehydrate
, What |is |dimethicone? | - Moisture |barrier |that |retards |water |loss
What |products |are |humectants? | - glycerin, |urea, |propylene |glycol, |lachydrin, |alpha
|hydroxy |acids
What |do |humectants | do? |- Water |attractants |- |increase |strateum |corneum |water
|content
Who |are |humectants | for? |- Only |for |xerosis |- |not |for |macerated |and |sometimes |not |for
|fragile |skin
Which |tissue |layer |is |most |susceptible |to |ischemic |damage? |- Muscle/fascia |layer
What |is |a |macule |- Flat |spot |of |color |change |less |than |0.5cm |in |diameter
|
What |is |a |papule |- Flat |spot |of |color |change | greater |than |0.5cm |in |diameter |What
| is |a |patch? |- Raised |spot |of |color |change |less |than |0.5cm |in |diameter |What
| is |a |plaque? |- Raised |spot |of |color |change | greater |than |0.5cm |in |diameter
| What |is |a |blister? |- Serous |fluid |trapped |under | skin |less |than |0.5cm |in |diameter
| What |is |a |bulla? |- Serous |fluid |trapped |under |skin |greater |than |0.5cm |in |diameter
| What |is |erythema? |- Generalized |redness
What |is |denudation? | - Loss |of |superficial |skin |layer
What |is |crusting? |- Scab |of |dried |exudate |of |body |fluid, |blood, |or |pus
What |is |granulation? | - proliferating |tissue |made |of |capillary |networks, |collagen, |and
|other |connective | substances
What |is |slough? |- | Loose, |stringy, |nonviable |tissue
| What |is |eschar? |- | Thick, |leathery, |necrotic |tissue
What |is |undermining? |- | Tissue |destruction |underlying |intact |skin |along |wound |margins
| What |is |tunneling? | - | Area |of |tissue |loss |extending | in |any |direction |from |edge |of |wound
| What |is |the |normal |water |content |of |the |skin? |- | 10-15%
What |is |friction |skin |damage? |- | | Mechanical | disruption |of |surface |layer |of |skin
solution
Goals |of |wound |assessment |- 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? |- | Impairs |leukocyte |function |and
|negatively |impacts |collagen |syntehesis, |development |of |tensile |strength, |epithelial
|resurfacing
What |BG |parameters |should | be |maintained | for |wound |healing? | - 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? | - 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? | - compromise |collagen
|synthesis/crosslinking
What |amino |acids |are |essential |for |collagen |synthesis?
What |is |the |effect |of |stress |on |these |amino | acids? |- Glutamine |and |l-arginine
|Not |adequately |produced |during |times |of |physiologic |stress
What |weight |trend |suggests |nutritional | deficiency? |- 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? | - <3.5 |g/dl
| What |serum |transferrin |level |indicates |malnutrition? | - <100mg/dl
What |serum |prealbumin |level |indicates |malnutrition? | - <19.5
|
What |total|lymphocyte |count |level |indicates |malnutrition? | - <1500
|
What |are |s/s |of |nutritional | deficits? |- 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? |- 30-35 |cal/kg |body |weight
| What |is |the |suggested |protein |intake? |- 1.25-1.5 |g/kg |body |weight
What |is |the |suggested |fluid |intake? |- 30ml |per |kg |(unless |fluid |restriction |indicated)
How |do |you |assess |perfusion/oxygenation? |- | 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? | - 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? | - renal |failure, |liver |failure,
|multisystem |trauma, |smoking, |advanced |age
What |are |the |layers |of |the |skin |- Epidermis
|Basement |Membrane |Zone
Dermis
| Subcutaneous
|Tissue
|Muscle/Fascia/Bone
What |are |the |layers |of |the |epidermis? |- Stratum |corneum |- |keratinocytes |filled |with
|keratin
Stratum |lucidum |- |only |in |palms/soles, |thick |areas
Stratum |granulosum | - |odland |bodies |secrete|ceramides, |lipophilic
|Stratum |spinosum | - |desmosomes |(cell |to |cell |junctions)
Stratum |germinativum | - |dermal-epidermal | junction
What |is |the |Basement |Membrane |Zone? |- Dermal-epidermal |junction
What |are |the |components |of |the |dermis? |- Papillary |dermis: |papillae |interlock |with |rete
|ridges, |capillary |loops, |sensitive |to |point |pressure
Reticular |dermis: |mostly |type |1 |collagen, |vasculars, |and |lymphatics
What |structures |of |the |skin |can |regenerate? |- Epidermis |and |parts |of |the |dermis
What |structures |of |the |skin |heal |by |scar |formation? |- Epidermal |appendages,
|Subcutaneous | tissue/fascia/muscle
How |is |newborn |skin |different? |- No |scars |up |to |2nd |trimester
|30% |thinner | skin
Faster |epidermal |turnover
,How |is |premature |infant | skin |different? |- Very |thin, |increased |fluid |loss, |functional
|stratum |corneum | at |30-32 |weeks
What |problems |may |arise |with |infant | skin? |- increased |permeability, |increased |MARSI
|risk, |extravasation, |diaper |dermatitis
How |do |you |mitigate |MARSI |risk |in |infants/elderly? |- avoid |tape |or |use |hydrocolloid
|base |or |silicone |adhesive, |no |alcohol |removers |only |mineral |oil, |petroleum, |silicone
|(preferred), |and |citrus)
How |do |you |mitigate |extravasation |in |an |infant? |- Hyaluronidase
|OR
phentolamine | if |vasoconstrictor
How |do |you |mitigate |diaper |dermatitis? |- Higher |pH
Use |petroleum |base |for |mild |erythema |and |zinc |oxide |for |denuded | skin
|sever |denudation | - |carboxymethylcellulose/petrolatum/zinc | oxide | (Ilex)
What |bathing |considerations | must |you |take |for |premature |infants? |- <30 |weeks|bathe
|with |water |only |for |2 |weeks
What |are |common |issues |with |older |skin? |- Thinner, |collagen |shrinks |and |causes
|wrinkles
Rete |ridges |and |dermal |papillae |flatten |- |increased |risk |for |tears/stripping |Reduced
|sebaceous |and |sweat |glands |- |dry |skin
Erratic/decreased |melanin | production
|Decreased |sensation |- |increased |trauma |risk
Loss |of |SubQ |tissue |- |increased |shear |and |decreased |insulation
|Increased |malignant | lesions |- |refer |to |derm
Reduced |blood |flow, |increased |epidermal |turnover | - |slow |healing
|Increased |senescense
Maybe|increased |inflammatory |mediators, |decreased |inhibitors
|Increased |capillary |fragility |(bruises)
What |strategies |keep |skin |healthy? | - pH |balanced |cleaners |- |no |alkaline |soaps
|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? |- mineral | oil, |petrolatum, |lanolin, | ceramides
What |do |emollients |do? |- penetrates |stratum |corneum |to |increase |lipid |component |and
|soften
Layer |on |skin |retards |water |loss |to|rehydrate
, What |is |dimethicone? | - Moisture |barrier |that |retards |water |loss
What |products |are |humectants? | - glycerin, |urea, |propylene |glycol, |lachydrin, |alpha
|hydroxy |acids
What |do |humectants | do? |- Water |attractants |- |increase |strateum |corneum |water
|content
Who |are |humectants | for? |- Only |for |xerosis |- |not |for |macerated |and |sometimes |not |for
|fragile |skin
Which |tissue |layer |is |most |susceptible |to |ischemic |damage? |- Muscle/fascia |layer
What |is |a |macule |- Flat |spot |of |color |change |less |than |0.5cm |in |diameter
|
What |is |a |papule |- Flat |spot |of |color |change | greater |than |0.5cm |in |diameter |What
| is |a |patch? |- Raised |spot |of |color |change |less |than |0.5cm |in |diameter |What
| is |a |plaque? |- Raised |spot |of |color |change | greater |than |0.5cm |in |diameter
| What |is |a |blister? |- Serous |fluid |trapped |under | skin |less |than |0.5cm |in |diameter
| What |is |a |bulla? |- Serous |fluid |trapped |under |skin |greater |than |0.5cm |in |diameter
| What |is |erythema? |- Generalized |redness
What |is |denudation? | - Loss |of |superficial |skin |layer
What |is |crusting? |- Scab |of |dried |exudate |of |body |fluid, |blood, |or |pus
What |is |granulation? | - proliferating |tissue |made |of |capillary |networks, |collagen, |and
|other |connective | substances
What |is |slough? |- | Loose, |stringy, |nonviable |tissue
| What |is |eschar? |- | Thick, |leathery, |necrotic |tissue
What |is |undermining? |- | Tissue |destruction |underlying |intact |skin |along |wound |margins
| What |is |tunneling? | - | Area |of |tissue |loss |extending | in |any |direction |from |edge |of |wound
| What |is |the |normal |water |content |of |the |skin? |- | 10-15%
What |is |friction |skin |damage? |- | | Mechanical | disruption |of |surface |layer |of |skin
