CPC Wound Care and Skin Assessment 2 — Questions and Answers

Question 1: Which of the following is the CORRECT sequence for wound irrigation using a syringe?

Irrigate with hydrogen peroxide, then normal saline
Irrigate with normal saline using a 30–60 mL syringe with an 18–19 gauge angiocath, directed at the wound surface (Correct answer)
Apply dry gauze packing and compress before irrigation
Irrigate with povidone-iodine to prevent infection, then rinse with water

Correct answer: Irrigate with normal saline using a 30–60 mL syringe with an 18–19 gauge angiocath, directed at the wound surface

Evidence-based wound irrigation uses normal saline or potable water delivered with sufficient pressure (4–15 psi) via a large syringe and angiocath. Hydrogen peroxide and povidone-iodine are cytotoxic to healing tissue and are not recommended.

Wound irrigation removes surface debris, reduces bacterial load, and promotes healing. The recommended technique uses normal saline or potable water at 4–15 psi pressure, achieved with a 30–60 mL syringe and 18–19 gauge angiocath. This pressure is sufficient to dislodge debris without driving bacteria deeper. Hydrogen peroxide is cytotoxic to fibroblasts and keratinocytes and should not be used in chronic wounds. Povidone-iodine (betadine) is similarly cytotoxic at standard concentrations and inhibits healing in granulating wounds. WOCN (Wound, Ostomy, and Continence Nurses) guidelines recommend isotonic solutions for wound cleansing.

Question 2: A community paramedic observes a sacral wound with undermining noted at the 3 o'clock and 9 o'clock positions. What does 'undermining' mean in wound assessment?

The wound has spread to involve deeper tissue planes below the visible surface
Tissue destruction extending beyond the wound edges under intact skin (Correct answer)
The wound is infected with anaerobic bacteria
The wound bed contains healthy granulation tissue

Correct answer: Tissue destruction extending beyond the wound edges under intact skin

Undermining refers to tissue destruction that extends under the intact skin surrounding the wound edges, creating a pocket or cave-like space. It is documented by clock position and depth measured with a cotton-tipped applicator.

Undermining is assessed by gently inserting a cotton-tipped applicator or gloved finger under the wound edges at each clock position and measuring the depth (in cm) of the tissue space. It differs from tunneling (sinus tract), which is a narrow channel extending in one direction from the wound. Undermining is more common in pressure injuries on bony prominences. Documentation format: 'Undermining present at 3 o'clock (2 cm) and 9 o'clock (1.5 cm).' Undermining indicates deeper tissue damage than the surface wound suggests and may require wound packing to prevent abscess formation and ensure healing from the base.

Question 3: Which dressing type is MOST appropriate for a heavily exudating wound with necrotic tissue?

Transparent film dressing
Calcium alginate dressing (Correct answer)
Hydrocolloid dressing
Dry sterile gauze

Correct answer: Calcium alginate dressing

Calcium alginate dressings are highly absorbent and appropriate for moderately to heavily exudating wounds. They also support autolytic debridement by maintaining a moist wound environment favorable for enzymatic breakdown of necrotic tissue.

Dressing selection is guided by exudate level and wound bed characteristics: Transparent films (low exudate, protection, autolytic debridement of shallow wounds), Hydrocolloids (low to moderate exudate, autolytic debridement, occlusive), Foams (moderate to heavy exudate, cushioning), Calcium alginates (moderate to heavy exudate, hemostatic, autolytic debridement of necrotic wounds), Hydrogels (dry wounds — adds moisture, autolytic debridement of eschar), Silver-impregnated dressings (critically colonized or infected wounds). For a heavily exudating wound with necrotic tissue, calcium alginate addresses both the high fluid burden and supports debridement.

Question 4: The Braden Scale for predicting pressure injury risk scores patients on six subscales. A total Braden Score of 12 indicates:

Low risk for pressure injury development
Moderate risk for pressure injury development
High risk for pressure injury development (Correct answer)
No risk — preventive measures are not needed

Correct answer: High risk for pressure injury development

Braden Scale risk categories: 15–23 = low risk, 13–14 = mild risk, 10–12 = moderate risk, ≤9 = severe risk. A score of 12 indicates high risk (moderate per some classifications), warranting intensive preventive interventions.

Wait — the Braden Scale ranges from 6 (lowest, highest risk) to 23 (highest, lowest risk). Standard risk classification: 15–18 = mild/at risk, 13–14 = moderate risk, 10–12 = high risk, ≤9 = very high risk. A score of 12 indicates HIGH risk. The six subscales assess: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Community paramedics calculate Braden Scores during home visits for bedridden or mobility-impaired patients and initiate preventive measures: repositioning schedules (every 2 hours), pressure redistribution surfaces, moisture barriers, and nutritional optimization.

Question 5: Which intervention is the CORNERSTONE of pressure injury prevention in a bedridden patient during home visits?

Applying antibiotic ointment to all bony prominences daily
Regular repositioning (every 2 hours) and pressure redistribution surfaces (Correct answer)
Restricting fluid intake to prevent skin moisture
Using ring cushions under the heels

Correct answer: Regular repositioning (every 2 hours) and pressure redistribution surfaces

Regular repositioning (at minimum every 2 hours) combined with pressure redistribution mattresses/overlays is the evidence-based cornerstone of pressure injury prevention, reducing sustained pressure on bony prominences.

Sustained pressure exceeding capillary closing pressure (~32 mmHg) for more than 1–2 hours causes tissue ischemia and pressure injury. Prevention strategies include: repositioning every 2 hours (or more frequently for high-risk patients), use of pressure redistribution surfaces (foam overlays, alternating pressure mattresses, low air loss mattresses), heel float devices (not ring cushions, which increase pressure), moisture barrier creams, nutritional optimization (protein 1.2–1.5 g/kg/day), and skin inspection at every repositioning. Community paramedics educate caregivers on repositioning techniques, repositioning schedules, and proper documentation of skin inspection findings.

Question 6: Which skin assessment finding is characteristic of a Stage 1 pressure injury?

Open, shallow wound with a red/pink wound bed
Non-blanchable erythema of intact skin (Correct answer)
Full-thickness skin loss with visible fat
Discolored but intact skin with possible bruising

Correct answer: Non-blanchable erythema of intact skin

Stage 1 pressure injuries present as non-blanchable erythema of intact skin — the area remains red when pressed (does not blanch), indicating reactive hyperemia with underlying tissue damage, unlike blanchable redness which is normal hyperemia.

Non-blanchable erythema is the hallmark of Stage 1 pressure injury. To test: apply firm pressure with a finger or transparent disc for 3 seconds. Blanchable erythema (turns white) indicates reactive hyperemia without tissue damage. Non-blanchable erythema (remains red) indicates existing microvascular damage. Stage 1 injuries occur over bony prominences (sacrum, heels, ischial tuberosities, trochanters). In individuals with darker skin tones, Stage 1 may present as discoloration, warmth, edema, or induration rather than visible redness, requiring careful palpation-based assessment. Community paramedics distinguish Stage 1 from Deep Tissue Pressure Injuries (purple/maroon discoloration) which indicate subsurface damage.

CPC Wound Care and Skin Assessment 2

Which of the following is the CORRECT sequence for wound irrigation using a syringe?