CWS Wound Care 5 — Questions and Answers
Question 1: Which skin tear classification system uses categories 1, 2, and 3 based on tissue loss?
- Payne-Martin Classification
- STAR Skin Tear Classification
- ISTAP Skin Tear Classification (Correct answer)
- Wagner Skin Tear System
Correct answer: ISTAP Skin Tear Classification
The ISTAP (International Skin Tear Advisory Panel) classification categorizes skin tears into Type 1 (no tissue loss), Type 2 (partial tissue loss), and Type 3 (total tissue loss).
Question 2: What is the MOST common cause of failure in split-thickness skin grafts?
- Infection at the donor site
- Hematoma or seroma formation beneath the graft (Correct answer)
- Inadequate donor skin thickness
- Hypergranulation at the recipient site
Correct answer: Hematoma or seroma formation beneath the graft
Hematoma and seroma formation beneath split-thickness skin grafts prevent vascular ingrowth (inosculation), which is the most common cause of graft failure.
Question 3: A patient with a non-healing diabetic foot ulcer has transcutaneous oxygen measurement (TcPO2) of 25 mmHg at the wound site. This value suggests:
- Excellent healing potential
- Adequate but borderline healing potential
- Impaired healing potential requiring further vascular evaluation (Correct answer)
- Normal arterial circulation
Correct answer: Impaired healing potential requiring further vascular evaluation
A TcPO2 below 30 mmHg indicates critically impaired tissue oxygenation with poor healing potential, warranting vascular workup and possible revascularization.
Question 4: Which moist wound healing principle does a hydrogel dressing PRIMARILY provide?
- Absorption of heavy exudate
- Donation of moisture to dry wounds (Correct answer)
- Antimicrobial protection
- Mechanical debridement
Correct answer: Donation of moisture to dry wounds
Hydrogels have a high water content (up to 96%) that donates moisture to dry or minimally exudating wounds, facilitating autolytic debridement.
Question 5: Epibole, also known as 'rolled wound edges' or 'epiboly,' is BEST managed by:
- Increasing wound moisture with occlusive dressings
- Mechanical or sharp disruption of the rolled epithelium (Correct answer)
- Applying topical corticosteroids to edges
- Leaving untreated as it resolves spontaneously
Correct answer: Mechanical or sharp disruption of the rolled epithelium
Epibole requires disruption of the rolled, non-migrating epithelial edges through sharp debridement, curettage, or chemical cauterization to restore lateral cell migration.
Question 6: Which type of pain assessment tool is MOST appropriate for evaluating wound-related pain in a cognitively impaired elderly patient?
- Numeric Rating Scale (NRS 0–10)
- Visual Analog Scale (VAS)
- FACES Pain Scale
- PAINAD (Pain Assessment in Advanced Dementia) (Correct answer)
Correct answer: PAINAD (Pain Assessment in Advanced Dementia)
The PAINAD scale assesses pain through behavioral observations (breathing, vocalization, facial expression, body language, consolability) in non-verbal or cognitively impaired patients.
Question 7: A patient develops periwound maceration. Which intervention BEST addresses this problem?
- Switch to a more absorbent dressing and apply a skin protectant (Correct answer)
- Increase dressing change frequency to every 8 hours
- Apply wet-to-dry gauze to dry out the periwound skin
- Use a hydrogel to add moisture to the affected area
Correct answer: Switch to a more absorbent dressing and apply a skin protectant
Maceration from excess moisture requires a more absorbent dressing to reduce exudate on periwound skin combined with a skin protectant (barrier cream or film) to protect the compromised skin.
CWS Wound Care 5
Which skin tear classification system uses categories 1, 2, and 3 based on tissue loss?