Wound Ulcer Care and Healing Worksheet
1. In your own words, describe an “ulcer” as would be used when describing an external wound.
~Ulcer is an opening of the skin due to the separating away of dead tissues that were previously inflamed.
2. What is the difference between a venous stasis ulcer and an arterial ulcer?
~Both of these ulcers are causes by either venous or arterial insufficiency and often affect the lower extremities of our body. They impair the exchange of oxygen and nutrients.
a. Arterial insufficiency causes tissue starvation because they aren’t able to bring blood and following processes, whereas venous insufficiency causes tissue congestion since they keep the used blood and thus block the processes that need to be done after the return.
b. Majority of the chronic and recurring are venous stasis ulcer, even though most of them have some effects from arterial insufficiency as well.
c. Venous stasis ulcer can be caused by the thrombosis. Reflux or the backflow can occur due to the obstruction in the veins. Arterial ulcer can be caused due to atherosclerosis, where artery linings are full of fatty plaque build-ups and thus couldn’t push enough blood and results in hypoxia.
d. The most distinctive sign between the two is that the arterial ulcers have well defined sharp-edges borders and pale bases (often surrounded by atrophic tissue), whereas venous ulcers have very irregular appearance in shape with shallow with sloping edges and have a red healthy base.
e. The most distinctive symptom between the two is the pain. Venous ulcer patients have variable pain levels from heavy to dull. The pain is relieved with leg elevation. Patients with the arterial ulcer experience completely opposite pain. Their pain is aggravated with leg elevation. Their pain is also described as sharp – stabbing, pinning, throbbing, burning, etc.
f. Venous ulcer detected with venous ultrasonography or venous angiography and magnetic resonance venography (MRV). Arterial ulcer can be detected with Ankle Brachial Index (ABI) with the use of Doppler device to find systolic blood pressure.
g. An effected treatment of venous ulcer would be to apply compression stocking to decrease edema and promote venous return. An intervention for arterial ulcer would be exercise and cessation of smoking to increase peripheral blood flow.
3. What is the difference between a laceration and an incision?
~Laceration and incision are both skin openings but laceration is often unintended, irregular, and rough wound, whereas incision is done intentionally for a purpose such as surgery and have clean edges.
4. Describe a stage 1 decubitus ulcer.
~It is a pressure-related alteration of a tissue. It is distinguished from normal skin based on skin temperature, tissue consistency or sensation. It appears red in light pigmented skin and red, blue or purple in darker skin. This ulcer is reversible by releasing the pressure.
5. Describe a stage 2 decubitus ulcer.
~In stage 2, loss of epidermis happens with minor damage to the dermis layer. The ulcer is obvious with the shallow crater/blister or swollen skin. It is painful. This is reversible too by releasing the pressure, however it takes several weeks.
6. Describe a stage 3 decubitus ulcer.
~In stage 3, subcutaneous tissue is also damaged and sometimes produces foul-smell. However the stage 3 is not painful compared to the stage 2, even though it takes months to heal with pressure reliefs.
7. Describe a stage 4 decubitus ulcer.
~In stage 4, damage occurs in tendons, muscles and even as deep as areas near to bones. It is deep and sometimes it may appear small, but it can tunnel underneath horizontally. It produces foul-smelling discharge. It can takes months to years to heal.
8. What type of nursing interventions should you provide when a patient exhibits a stage 1 decubitus?
~The patient with stage 1 decubitus ulcer is at extreme risk for skin openings. The patient needs to release the pressure from the location that is exhibiting the stage 1 and assess other sites as well; this could be done via turning or off-loading from positions that is causing the pressure. The ulcer site has to be kept clean and dry. More physical activity may be desired, if not already doing that. More nutrition intake and monitor the healing while providing any medications/treatment ordered by the doctor. Apply protective dressings. Check for medication side effects that could be causing the ulcer.
9. What type of nursing interventions should you provide when a patient exhibits a stage 2 decubitus?
~The nursing interventions for a patient with a stage 2 decubitus ulcer will include the following in addition to the stage 1: if the tissue necrosis and granulation has occurred, the debridement is necessary. Apply skin protectant creams. The doctor might order dressing changes.
10. What is an oil emulsion dressing, and when is it most likely to be used.
~Oil emulsion dressing is impregnated with petroleum in an emulsion blend so that the dressing is no adhering to the wound area. It’s a knitted mesh fabric and has enough porosity that allows the easy flow of exudates drainages. It is most likely to be used when the wounds that are draining as a result of burn, pressure ulcer, surgery, abrasions, etc.
11. If you had a large open wound and you could see red beefy tissue at the bottom of the wound, what would you call that tissue? Is this tissue a positive sign of wound healing?
~Red beefy tissue usually indicated granulation of a tissue. It indications the wound healing and typically grows from the base of the wound. It replaces fibrin clot in wound healing.
12. If your patient has a decubitus ulcer on their heel, and this wound is covered by a thick layer of dark, firm tissue that is well adhered to the wound bed, how would you describe this? What stage is this wound?
~It’s an eschar. But the stage of this wound is unstageable because the depth of the wound is covered by a necrotic tissue.
13. Your patient has an open wound that has some stringy, soft tissue that is yellowish or grayish in color and somewhat adhered to the wound bed, what would this tissue be called?
~This tissue called slough.
14. If your patient’s wound is draining a clear yellow drainage without odor, how would you describe this exudate?
15. Your patient has deep, open wound that was caused by pressure, with some pink tissue at the base, about 50% grey/green stringy tissue adhered to the wound bed, and reddish, orange watery drainage that has soaked into most of the dressing. The skin around the wound is pink in color and feels a little warm. How would you describe the wound in your documentation?
~The grey/green stringy tissue means the necrotic tissues are sloughing away. The drainage reddish, orange and watery fluids are serous and sero-sanguinous wound exudates. The pink color skin around the wound shows that it is fragile but possibly healing as well.
16. What type wound care would most likely be ordered for the wound you described?
~Because the wound is still discharging exudates, dry to wet dressing might be ordered to soak all of them. Irrigation also seems essential to clean the wound drainage. Packing also seems viable for the wound has stringy tissue attached to the bed.
17. Your post-surgical patient has a wound sutured into her mastectomy incision. It has a JP suction bulb that is to be emptied every shift. The drainage is bright red, and bloody in appearance. How is this type of drainage described, and how would you prevent clots from sticking in the tubing?
~Bright red and blood appearance drainage are described as sanguinous. To prevent clots from sticking in the tubing, the action called stripping and milking is taken. It is done by using the fingers to squeeze the along the drain tubing to maintain the flow. Cloth or alcohol swab can also be used to clear the drainage.
18. You observe your charge nurse squirting sterile water into a patients open wound. What is the most likely reason for doing this, and what is the correct terminology?
~This process is called irrigating. Irrigating process cleans the wound and helps removes the bacteria, discharge and debris. It also prevents the infection.
19. What changes might need to be made to your patient’s diet to enhance wound healing?
~To enhance wound healing, the most essential nutrients include protein, vitamin A, vitamin C and zinc. So the diet could include whole grain bread and cereals, dairy products such as yogurt, vegetables and fruits. Calories are also necessary; but it is already in most of these diets.
20. Your patient is diabetic and has an ulcer on the base of his left great toe. Despite wet to dry dressing changed BID the wound measures 2cm by 2.2cm, and one month ago it measured 1.8cm by 2.1cm. He has avoided pressure to the area by limiting ambulation and wearing a special shoe with cut out areas for his toe. Explain why he may be experiencing problems with healing.
Even though the patient avoided giving pressure to the area by limiting ambulation, it may be adversely affecting his ulcer by decrease circulation in that affected area. Also the dressing changes has to be sterile technique, else it could promote the infection to the surround area. Proper nutrition along with good treatment regimen is also important; with their absence, the condition of wound may decline.
21. An obese patient suffered wound dehiscence one week following abdominal surgery to remove a lacerated spleen. The doctor does not plan to attempt closure of the wound, but has opted to order wet wound dressings TID. By what means will this wound heal, and why would the doctor order this treatment?
~The primary reason for wet dressing is to promote moist environment for granulation and healing. It the wound gets too dry, it could be painful. The dehiscence might not be too large to risk the complications that could result from attempting the closure of the wound. The doctor may be intending to allow for drainage or removal of infectious debris and promotion of granulation through second-intention healing.
22. When providing wound care, you remove this soiled dressing, and then remove your gloves. Why do you change your gloves in the middle of providing care?
~Because the gloves got contaminated with soiled dressing. I need to keep the gloves sterile/clean for the process following – applying new dressings, etc.
23. If doing a sterile dressing change, you set up a sterile field and place your open sterile dressings on the field. Why would you want to avoid reaching across the sterile field once it has been set up?
~Sterile field might be compromised if you reach across because only the sterile gloved hand is sterile; rest of our body parts are not sterile, including the arms that shouldn’t be reaching across the field.
Textbook of Basic Nursing by Caroline Rosdahl and Mary Kowalski.
Venous vs. arterial leg ulcers:
Microvascular Breast Reconstruction Drain Care: http://medicalcenter.osu.edu/PatientEd/Materials/PDFDocs/procedure/tube-care/MicrovascularDrainCare.pdf
Understand Wound Dehiscence