OSCE OSCE Wound Care and Dressings — Questions and Answers

Question 1: When assessing a wound in an OSCE, which mnemonic is commonly used to structure wound assessment documentation?

TIMES: Tissue, Infection/Inflammation, Moisture, Edge, Surrounding skin (Correct answer)
SBAR: Situation, Background, Assessment, Recommendation
ABCDE: Airway, Breathing, Circulation, Disability, Exposure
SOCRATES: Site, Onset, Character, Radiation, Associated symptoms, Time, Exacerbating/relieving factors, Severity

Correct answer: TIMES: Tissue, Infection/Inflammation, Moisture, Edge, Surrounding skin

The TIMES framework provides a structured approach to wound assessment: Tissue type, signs of Infection/Inflammation, Moisture balance, wound Edge condition, and Surrounding skin.

The TIMES framework (Falanga, 2000; World Union of Wound Healing Societies, 2004) guides wound bed preparation: T = Tissue (non-viable/necrotic tissue inhibits healing — needs debridement), I = Infection/Inflammation (clinical infection signs require systemic/topical treatment), M = Moisture (balance: exudate management to avoid maceration or desiccation), E = Edge (non-advancing or undermining wound edges indicate barriers to healing), S = Surrounding skin (erythema, maceration, induration, breakdown). Systematic assessment using TIMES guides dressing selection, debridement decisions, and referral for specialist input.

Question 2: Which wound dressing is most appropriate for a wound with moderate-to-heavy exudate?

Alginate or foam dressing — high absorbency manages heavy exudate (Correct answer)
Transparent film dressing — only suitable for low exudate wounds
Hydrocolloid dressing — suitable for light exudate only
Dry gauze — insufficient moisture management for heavy exudate

Correct answer: Alginate or foam dressing — high absorbency manages heavy exudate

Alginate and foam dressings have high absorptive capacity and are designed for moderate-to-heavy exuding wounds.

Dressing selection is guided by wound characteristics, particularly exudate level: Low exudate: hydrocolloid, transparent film, hydrogel. Moderate exudate: foam, hydrofibre. Heavy exudate: alginate (made from seaweed-derived fibres that gel on contact with exudate), foam (polyurethane-based), super-absorbent polymer dressings. Alginate dressings are also haemostatic (useful for bleeding wounds) and conform well to irregular wound shapes. Choosing an inappropriate dressing (e.g., hydrocolloid on a heavily exuding wound) leads to leakage, maceration of surrounding skin, and increased infection risk.

Question 3: What is the correct classification for a pressure ulcer where full-thickness skin loss exposes subcutaneous fat but bone, tendon, and muscle are not visible?

Category/Stage 3 pressure ulcer (Correct answer)
Category/Stage 2 — partial thickness skin loss
Category/Stage 4 — full thickness with exposed bone
Unstageable — wound bed not visible

Correct answer: Category/Stage 3 pressure ulcer

Category 3 pressure ulcers involve full-thickness skin loss with visible subcutaneous fat, but without exposed bone, tendon, or muscle.

The NPUAP/EPUAP pressure ulcer classification system: Category 1 = non-blanchable erythema of intact skin; Category 2 = partial-thickness skin loss (dermis) — shallow open ulcer or intact blister; Category 3 = full-thickness skin loss exposing subcutaneous fat (fascia, bone, tendon, muscle not visible — if visible, it is Category 4 or unstageable); Category 4 = full-thickness skin loss with exposed bone, tendon, or muscle; Unstageable = wound bed obscured by slough/eschar; Suspected deep tissue injury = purple/maroon discolouration or blood-filled blister over intact skin. Accurate staging guides treatment and resource allocation.

Question 4: Before applying a sterile dressing in an OSCE, what is the most critical infection-prevention step?

Performing hand hygiene and applying sterile/non-touch technique throughout the procedure (Correct answer)
Wearing a face mask only
Cleaning the trolley with soap and water alone
Applying gloves without prior hand hygiene

Correct answer: Performing hand hygiene and applying sterile/non-touch technique throughout the procedure

Hand hygiene (before and after) combined with an aseptic non-touch technique (ANTT) prevents wound contamination and reduces healthcare-associated infection risk.

Aseptic Non-Touch Technique (ANTT) is the evidence-based approach for wound dressing procedures in healthcare. Key principles: Hand hygiene (WHO 5 moments — especially before and after); Preparation of a sterile field using a dressing pack; Non-touch technique — never contaminate key parts (wound, inner dressing surface) by direct contact; Appropriate use of sterile gloves for direct wound contact. Gloves do NOT replace hand hygiene; hands are decontaminated before donning and after removing gloves. ANTT prevents surgical site infections, wound contamination, and healthcare-associated infections, which are leading causes of patient morbidity.

Question 5: What does 'wound debridement' mean, and why is it important for wound healing?

Removal of non-viable (necrotic/sloughy) tissue to convert a chronic wound into an acute healing environment (Correct answer)
Applying antibiotics to a wound without removing dead tissue
Covering a wound to prevent air exposure
Irrigating a wound with antiseptic solution only

Correct answer: Removal of non-viable (necrotic/sloughy) tissue to convert a chronic wound into an acute healing environment

Debridement removes necrotic tissue, slough, bacteria, and biofilm that impede healing, creating a viable wound bed that supports the healing cascade.

Wound debridement is the removal of devitalised tissue, foreign material, slough, necrotic eschar, and biofilm from a wound bed. Non-viable tissue harbours bacteria, impairs granulation tissue formation, and prolongs the inflammatory phase of healing. Methods include: Surgical/sharp debridement (scalpel/scissors — fastest, requires competency and pain management); Autolytic debridement (moisture-retentive dressings allow endogenous enzymes to break down non-viable tissue — slowest but non-invasive); Enzymatic debridement (topical enzymes); Biological debridement (larval/maggot therapy — highly effective for sloughy wounds); Mechanical (wet-to-dry, irrigation — less selective). Method selection depends on wound type, tissue vitality, patient condition, and clinical setting.

Question 6: Which type of wound healing is characterized by surgical closure with sutures or staples?

Primary intention (first intention) (Correct answer)
Secondary intention
Tertiary/delayed primary intention
Granulation-based healing

Correct answer: Primary intention (first intention)

Primary intention healing involves wound closure by direct apposition of wound edges (sutures, staples, steri-strips), resulting in minimal scarring and rapid healing.

The three types of wound healing: Primary intention = edges directly opposed (sutured, stapled, glued) — minimal granulation tissue required, rapid closure, minimal scarring (e.g., surgical incisions, lacerations). Secondary intention = edges left open to heal from the base up through granulation, contraction, and epithelialisation — larger wounds, contaminated wounds, pressure ulcers (longer healing time, more scarring). Tertiary/delayed primary intention = wound left open initially (due to contamination/infection risk), then surgically closed after 3–5 days once clean — used for traumatic wounds or contaminated surgical sites. Understanding healing intention guides dressing choice, wound monitoring, and patient education.

Question 7: A wound dressing that maintains a moist wound environment and is suitable for clean, shallow wounds with low exudate is:

Hydrocolloid dressing (Correct answer)
Alginate dressing
Dry gauze
Iodine-impregnated gauze

Correct answer: Hydrocolloid dressing

Hydrocolloid dressings create an optimal moist wound environment, promoting autolytic debridement and epithelialisation in low-exudate wounds.

Hydrocolloid dressings (e.g., DuoDERM, Comfeel) contain hydrophilic colloid particles (carboxymethylcellulose, gelatin, pectin) in an adhesive matrix. When in contact with wound exudate, they form a soft gel that maintains moisture, promotes autolytic debridement, reduces pain (moist environment reduces exposed nerve endings), and protects from mechanical trauma. They are suitable for superficial partial-thickness wounds, Category 2 pressure ulcers, and minor burns with low exudate. Not suitable for infected wounds, heavily exuding wounds, or wounds requiring daily inspection. They can be left in place for 3–7 days, reducing disturbance frequency.

Question 8: Which sign most strongly indicates wound infection rather than normal inflammation?

Increasing or spreading erythema, warmth, purulent exudate, malodour, or failure to progress after appropriate treatment (Correct answer)
Mild pink colouration at wound edges immediately after injury
Clear serous exudate in a healing wound
Wound contraction and scar formation

Correct answer: Increasing or spreading erythema, warmth, purulent exudate, malodour, or failure to progress after appropriate treatment

Infection is characterized by spreading erythema, pus, offensive odour, increasing pain, delayed healing, and systemic signs; these exceed expected normal inflammatory response.

Distinguishing normal healing inflammation from wound infection is critical. Normal inflammation: localised erythema limited to wound margins, warmth, mild swelling, serous or serosanguinous exudate — expected in days 1–4 post-injury. Signs of LOCAL infection (NERDS): Non-healing wound, Exudate increase, Red friable granulation tissue, Debris/necrotic tissue, Smell. Signs of SPREADING infection (STONEES): Size increase, Temperature elevation, Os (exposed bone), New areas of breakdown, Erythema spreading, Exudate increase, Smell. Systemic infection signs: fever, elevated CRP/WBC, sepsis. Culture and sensitivity testing guides antibiotic selection; antimicrobial dressings (silver, iodine) may be used for local infection control.

Question 9: What is the purpose of negative pressure wound therapy (NPWT / VAC therapy)?

To apply sub-atmospheric pressure to remove exudate, reduce oedema, stimulate granulation tissue formation, and promote wound closure (Correct answer)
To apply positive pressure to force blood into ischaemic wound tissue
To provide chemical debridement only
To waterproof a wound during bathing

Correct answer: To apply sub-atmospheric pressure to remove exudate, reduce oedema, stimulate granulation tissue formation, and promote wound closure

NPWT applies continuous or intermittent sub-atmospheric pressure to a wound via a sealed foam dressing and canister system, promoting healing in complex wounds.

Negative pressure wound therapy (NPWT), commercially known as VAC (vacuum-assisted closure) therapy, uses a sealed foam or gauze dressing connected to a vacuum pump. The sub-atmospheric pressure (typically -75 to -125 mmHg) produces multiple effects: continuous exudate removal, reduced interstitial oedema, mechanical micro-deformation stimulating cell proliferation, increased local blood flow, reduction of bacterial burden, and wound edge contraction. NPWT is used for complex, chronic wounds including diabetic foot ulcers, pressure injuries, dehisced surgical wounds, and post-fasciotomy wounds. Contraindications include untreated osteomyelitis, malignancy in wound, fistulae to body cavities, and exposed vessels/organs without protective coverage.

Question 10: When cleansing a wound in an OSCE, what is the recommended irrigation solution for most clean wounds?

Normal saline (0.9% sodium chloride) or potable water (Correct answer)
Neat chlorhexidine antiseptic solution
Hydrogen peroxide
Povidone-iodine undiluted

Correct answer: Normal saline (0.9% sodium chloride) or potable water

Normal saline or clean tap water (potable water) is safe and effective for wound irrigation; antiseptic solutions can damage fragile healing tissue and should be used selectively.

Evidence-based wound cleansing guidelines recommend isotonic normal saline (0.9% NaCl) or clean potable tap water for irrigation of most wounds. These are non-cytotoxic (do not damage fibroblasts, keratinocytes, or white blood cells) and effectively remove surface bacteria, debris, and necrotic material. Antiseptic solutions (chlorhexidine, povidone-iodine, hydrogen peroxide) are cytotoxic to healing cells at standard concentrations and should be used selectively for infected wounds or biofilm, with dilute concentrations or time-limited application. Irrigation pressure (10–15 psi using a 19G needle and 35mL syringe, or a commercial wound irrigator) is as important as solution choice for removing bacteria.

Question 11: Which of the following is the correct sequence for a wound dressing change procedure in an OSCE?

Hand hygiene → explain procedure and gain consent → prepare equipment → clean gloves to remove soiled dressing → hand hygiene → sterile gloves + ANTT to clean and apply new dressing → dispose of waste → document (Correct answer)
Apply gloves → remove old dressing → immediately apply new dressing without hand hygiene
Clean wound → gain consent → apply new dressing → document
Use non-sterile gloves for entire procedure to save time

Correct answer: Hand hygiene → explain procedure and gain consent → prepare equipment → clean gloves to remove soiled dressing → hand hygiene → sterile gloves + ANTT to clean and apply new dressing → dispose of waste → document

The correct sequence follows ANTT principles: preparation, consent, non-sterile gloves for removal, hand hygiene between steps, sterile technique for cleaning and new dressing application.

The correct wound dressing procedure: (1) Explain procedure and gain informed consent; (2) Perform hand hygiene (WHO technique); (3) Prepare sterile dressing trolley/pack; (4) Don clean (non-sterile) gloves; (5) Remove soiled dressing and dispose in clinical waste; (6) Remove gloves and perform hand hygiene again; (7) Don sterile gloves or use ANTT with forceps; (8) Assess wound (TIMES framework); (9) Irrigate with saline if required; (10) Apply appropriate dressing; (11) Secure and label with date; (12) Remove gloves, perform hand hygiene; (13) Document wound assessment, dressing used, and next dressing change date; (14) Dispose of clinical waste appropriately.

Question 12: Sloughy wound tissue appears as what colour, and what does it indicate?

Yellow or tan — moist, non-viable tissue that impedes healing and requires debridement (Correct answer)
Bright red — actively bleeding healthy granulation tissue
Pink — new epithelium covering the wound surface
Black — dry necrotic eschar from full-thickness ischaemic tissue loss

Correct answer: Yellow or tan — moist, non-viable tissue that impedes healing and requires debridement

Slough is yellow/tan moist non-viable fibrinous tissue that needs removal via debridement to allow granulation tissue formation.

Wound bed tissue types by colour: Black/brown eschar = dry, hard necrotic tissue — ischaemic full-thickness tissue death — requires surgical, enzymatic, or autolytic debridement (unless dry eschar on ischaemic heel — may protect if no signs of infection). Yellow/tan slough = moist, fibrinous non-viable tissue — contains bacteria and debris — impedes healing — requires debridement. Red granulation tissue = healthy, moist granulation tissue — indicative of wound healing progress — protect and maintain moist environment. Pink/pale epithelium = new epithelial tissue covering wound surface — fragile, requires protection. Documentation of wound bed tissue percentages (e.g., 40% slough, 60% granulation) tracks healing progress.

Question 13: What does the 'TIME' principle in wound bed preparation stand for?

Tissue management, Inflammation/Infection control, Moisture balance, Edge (epithelial) advancement (Correct answer)
Temperature, Irrigation, Medication, Exercise
Touch, Inspect, Measure, Evaluate
Tissue, Incision, Medication, Elevation

Correct answer: Tissue management, Inflammation/Infection control, Moisture balance, Edge (epithelial) advancement

TIME is a framework for wound bed preparation: address non-viable Tissue, control Infection/Inflammation, balance Moisture, stimulate Edge (epithelial) advancement.

The TIME framework (Schultz et al., 2003) provides a systematic approach to overcoming barriers to wound healing: T (Tissue) = remove non-viable tissue (necrosis, slough, foreign material) that inhibits healing; I (Infection/Inflammation) = control critical colonisation, biofilm, and clinical infection; address excessive or prolonged inflammation; M (Moisture) = balance wound moisture — desiccation delays re-epithelialisation, excessive moisture causes maceration and perilesional skin breakdown; E (Edge) = assess and address non-advancing or undermining wound edges (may indicate biofilm, poor perfusion, or cells that have become senescent). TIME guides both dressing selection and advanced wound care decisions.

Question 14: A patient has a venous leg ulcer. Which dressing and compression approach is most evidence-based?

Moist wound dressings combined with multi-layer compression bandaging to address venous hypertension (Correct answer)
Dry gauze dressings with no compression as compression may worsen pain
High-pressure arterial compression bandages
Only topical antibiotics without compression

Correct answer: Moist wound dressings combined with multi-layer compression bandaging to address venous hypertension

Venous leg ulcers are caused by venous hypertension; evidence shows compression therapy (multi-layer bandaging) is the cornerstone of treatment, combined with appropriate wound dressings.

Venous leg ulcers (VLUs) account for approximately 60–80% of chronic leg ulcers and result from chronic venous insufficiency with venous hypertension. The evidence-based treatment is sustained, graduated multi-layer compression bandaging (e.g., 4-layer bandaging) or compression hosiery (once healed), which reduces venous hypertension, improves venous return, reduces oedema, and stimulates healing. Before applying compression, arterial insufficiency must be excluded (ABPI — ankle-brachial pressure index should be >0.8 for full compression). Wound dressings are secondary to compression and should maintain a moist wound environment. NPWT and advanced wound care products may augment healing in complex cases.

Question 15: When documenting wound size in an OSCE, what measurements should be recorded?

Length (longest diameter), width (widest perpendicular diameter), and depth; also document undermining and sinus tracts if present (Correct answer)
Width only, measured at the widest point
Area only, calculated as length × width without depth
Wound circumference using a tape measure

Correct answer: Length (longest diameter), width (widest perpendicular diameter), and depth; also document undermining and sinus tracts if present

Standardized wound measurement includes length × width × depth; documenting undermining and sinus tracts provides a complete 3D picture of wound status.

Standardized wound measurement protocol: Length = longest dimension, measured head-to-toe (superior-inferior) using a ruler or wound measuring guide; Width = widest diameter perpendicular to length (medial-lateral); Depth = deepest point, measured by inserting a sterile cotton-tipped applicator to the wound base and marking the skin level. Additionally: Undermining = tissue destruction under intact skin at wound edges — measured by inserting a probe and recording depth and clock-face position; Sinus tracts/tunnelling = channels extending into the tissue beyond the visible wound edges. All measurements are recorded in centimetres. Serial measurements assess healing trajectory and treatment response.

Question 16: Which type of debridement is most selective, only removing non-viable tissue without damaging healthy wound tissue?

Autolytic debridement (using moisture-retentive dressings to activate the body's own enzymes) (Correct answer)
Sharp/surgical debridement
Mechanical debridement (wet-to-dry dressings)
Pulsatile lavage

Correct answer: Autolytic debridement (using moisture-retentive dressings to activate the body's own enzymes)

Autolytic debridement harnesses the body's endogenous proteolytic enzymes under moisture-retentive dressings to selectively liquefy non-viable tissue while leaving healthy tissue intact.

Autolytic debridement is the most selective form of debridement because it relies on endogenous enzymes (matrix metalloproteinases, phagocytes) present in wound exudate to selectively digest non-viable tissue. Moisture-retentive dressings (hydrocolloids, hydrogels, transparent films) create the fluid environment necessary for enzymatic activity while protecting the wound. Advantages: painless, non-invasive, no damage to healthy tissue, suitable for patients who cannot tolerate sharp debridement. Disadvantages: slow (days to weeks), not suitable for infected wounds or ischaemic wounds, requires careful monitoring for infection. Hydrogel sheets/amorphous gels are particularly useful for rehydrating dry eschar to facilitate autolysis.

Question 17: What is the significance of a wound with 'rolled/epibolic wound edges' in chronic wound assessment?

The wound edges have rolled inward, preventing epithelial cell migration across the wound surface — requiring edge debridement or biological therapies (Correct answer)
Rolled edges indicate the wound is healing well and closing normally
Epibolic edges are a sign of infection requiring immediate antibiotics
Rolled edges are only significant in surgical wounds, not pressure ulcers

Correct answer: The wound edges have rolled inward, preventing epithelial cell migration across the wound surface — requiring edge debridement or biological therapies

Epibolic (rolled/callused) wound edges prevent keratinocytes from migrating across the wound bed to close it — a significant barrier to healing requiring specific intervention.

Epibolic (rolled) wound edges are a key barrier to healing identified in wound assessment. Normally, epithelial cells at the wound edge migrate across the wound surface to close it (epithelialisation). When edges become rolled or callused (common in chronic wounds, venous ulcers, diabetic foot ulcers), keratinocytes differentiate down into the dermis rather than migrating horizontally across the wound, preventing closure. Management includes: sharp debridement of the edges to create a fresh, bleeding wound edge that restimulates migration; chemical cautery (silver nitrate); negative pressure wound therapy; or biological agents (growth factors, cellular/tissue-based products). Wound edge assessment is a critical component of the TIMES framework.

Question 18: Which pressure relief intervention is most important for preventing and treating sacral pressure ulcers?

Regular repositioning (every 2 hours or per care plan), use of pressure-redistributing mattresses/overlays, and proper positioning (Correct answer)
Applying a thick dressing to the sacrum without repositioning
Restricting oral intake to reduce tissue swelling
Using a standard hospital foam mattress only

Correct answer: Regular repositioning (every 2 hours or per care plan), use of pressure-redistributing mattresses/overlays, and proper positioning

Regular repositioning every 2 hours reduces sustained pressure over bony prominences; pressure-redistributing surfaces (foam, gel, air mattresses) reduce peak pressures. Both are essential.

Pressure ulcer prevention requires a multi-faceted approach addressing the underlying mechanism (sustained pressure, shear, friction, microclimate). Key interventions: (1) Regular repositioning — the cornerstone of prevention; 30° tilted side-lying position reduces sacral pressure more than 90° side-lying; repositioning frequency guided by individual risk assessment; (2) Pressure-redistributing equipment — reactive (standard foam, low-air-loss) and active (alternating pressure) mattresses significantly reduce sacral pressure; (3) Skin assessment — especially over bony prominences with each repositioning; (4) Nutrition optimisation — protein and micronutrients essential for tissue integrity; (5) Moisture management — incontinence care to prevent skin maceration. Prophylactic dressings (multi-layer foam) over the sacrum reduce friction/shear but do not replace repositioning.

Question 19: What is a 'fistula' in the context of wound care, and what is the clinical significance?

An abnormal tract connecting two epithelial-lined surfaces (e.g., gut to skin or bladder to vagina) — may produce persistent wound contamination, requiring specialist management (Correct answer)
A superficial skin crack from dry skin requiring emollient only
A type of wound dressing used for deep cavity wounds
A normal variant of wound healing in elderly patients

Correct answer: An abnormal tract connecting two epithelial-lined surfaces (e.g., gut to skin or bladder to vagina) — may produce persistent wound contamination, requiring specialist management

A fistula is an abnormal communication between two body surfaces or cavities — wound fistulae can contaminate wound beds with enteric or urinary content, severely impeding healing.

A fistula (from Latin = pipe/tube) is an abnormal passageway connecting two epithelial surfaces. In wound care, common types include: enterocutaneous fistula (gut to skin — contents contaminate wound), colocutaneous, vesico-cutaneous (bladder to skin), and rectovaginal. Fistulae can result from Crohn's disease, radiation damage, malignancy, surgical anastomotic leak, or trauma. Management is complex, often requiring: pouch systems to collect effluent and protect skin, aggressive nutritional support (high output fistulae cause significant protein and electrolyte loss), control of underlying disease, and potentially surgical correction. NPWT therapy may reduce fistula output in some cases. All wound fistulae require specialist referral.

Question 20: In an OSCE wound care station, a wound swab is taken. When is swabbing indicated?

When there are clinical signs of infection (increasing pain, erythema, purulent exudate, malodour, systemic signs) — not routinely for all wounds (Correct answer)
Every time a dressing is changed, regardless of signs
To confirm the wound is clean before applying a new dressing
Only if the patient requests it

Correct answer: When there are clinical signs of infection (increasing pain, erythema, purulent exudate, malodour, systemic signs) — not routinely for all wounds

Wound swabbing should be performed only when there are clinical signs of infection, not routinely — all wounds are colonised with bacteria and routine swabbing is not clinically useful.

All chronic wounds are colonised (bacteria present without clinical effect) or critically colonised (bacteria delay healing without classic infection signs). Only clinically infected wounds (producing NERDS/STONEES signs) require swabbing to guide antibiotic therapy. The correct swabbing technique (Levine technique) uses a moistened sterile swab rotated over a 1 cm² area of cleansed granulation tissue with sufficient pressure to express fluid from the tissue — not a surface swab of exudate. Results should be interpreted alongside clinical signs, as 90% of wound swabs grow multiple organisms; the clinically significant pathogen must be identified from the clinical context. Routine swabbing wastes resources and may produce misleading results.

Question 21: Which topical dressing ingredient provides antimicrobial activity and is appropriate for use in critically colonised or locally infected wounds?

Silver (ionic silver or silver-containing dressings) (Correct answer)
Petroleum jelly impregnated gauze
Simple foam dressings without additives
Hydrogel amorphous gel without antimicrobials

Correct answer: Silver (ionic silver or silver-containing dressings)

Silver ions have broad-spectrum antimicrobial activity against bacteria including MRSA; silver dressings are evidence-based for managing critical colonisation and local wound infection.

Silver-containing dressings (silver-coated foam, silver-impregnated hydrofibre/alginate, nanocrystalline silver) release silver ions (Ag+) that disrupt bacterial cell walls, enzyme systems, and DNA replication. Silver has broad-spectrum activity against Gram-positive (including MRSA), Gram-negative, and some fungal organisms. Indications: critically colonised wounds (healing delayed despite optimal management), locally infected wounds (NERDS signs), wounds with known or suspected antimicrobial-resistant organisms. Silver dressings should not be used indefinitely — reassess after 2 weeks and discontinue if infection signs resolve to avoid cytotoxicity and antibiotic stewardship concerns. Other antimicrobial dressings include iodine-containing dressings (cadexomer iodine — slower release), honey-based dressings (manuka honey — activity via osmotic effect and H2O2 generation), and PHMB (polyhexamethylene biguanide).

Question 22: A patient with a diabetic foot ulcer has a Wagner Grade 3 classification. What does this indicate?

Deep ulcer with abscess formation, osteomyelitis, or tendon/joint capsule involvement (Correct answer)
Superficial ulcer limited to skin and subcutaneous tissue
Full-thickness ulcer extending to bone without infection
Forefoot gangrene

Correct answer: Deep ulcer with abscess formation, osteomyelitis, or tendon/joint capsule involvement

Wagner Grade 3 indicates deep infection with osteomyelitis, tendon involvement, or abscess — a serious complication requiring urgent orthopaedic and vascular assessment.

The Wagner Diabetic Foot Ulcer Classification: Grade 0 = no open lesion but high-risk foot (callus, deformity); Grade 1 = superficial ulcer (skin/subcutaneous tissue); Grade 2 = deep ulcer to tendon, capsule, or bone without infection; Grade 3 = deep ulcer with osteomyelitis, abscess, or septic joint; Grade 4 = partial forefoot gangrene; Grade 5 = whole foot gangrene. Wagner Grade 3 signals major infection risk; osteomyelitis is diagnosed with MRI (gold standard) or X-ray. Management requires surgical debridement, long-course antibiotics guided by bone biopsy culture, possible amputation, and multidisciplinary input (vascular surgery, orthopaedics, diabetes specialist, dietitian, tissue viability nurse). ABPI/vascular assessment is essential to ensure healing potential.

Question 23: When managing a wound with surrounding skin maceration, which intervention is most appropriate?

Apply a skin barrier cream or film to protect the surrounding skin and change to a more absorbent dressing to reduce exudate contact with skin (Correct answer)
Apply more dressings to cover the moist area
Use a tighter bandage to compress the wound
Discontinue all dressings and leave the wound exposed to air

Correct answer: Apply a skin barrier cream or film to protect the surrounding skin and change to a more absorbent dressing to reduce exudate contact with skin

Maceration results from excessive moisture contact with the periwound skin; barrier products protect the skin while switching to a more absorbent dressing addresses the root cause.

Periwound maceration (white, soggy, wrinkled, fragile skin around a wound) results from prolonged contact with wound exudate. It weakens the skin barrier, extending the wound area and increasing infection risk. Management: (1) Skin protection — apply a no-sting skin barrier film (e.g., Cavilon, Mepitel One) or paste (zinc oxide, Vaseline) to protect periwound skin from moisture; (2) Dressing upgrade — switch from a low-absorbency dressing to a foam, alginate, or hydrofibre dressing with appropriate exudate management capacity; (3) Address exudate source — treat underlying infection or increase compression for venous oedema. Correctly sizing the dressing so the absorbent pad covers only the wound (not surrounding skin) also minimises maceration.

Question 24: What is the 'healing trajectory' concept in wound care assessment?

The expected rate of wound area reduction over time — typically >50% area reduction in 4 weeks predicts successful healing (Correct answer)
The path a wound probe takes when assessing depth
The anatomical location along which infection can spread
The sequence of debridement techniques applied

Correct answer: The expected rate of wound area reduction over time — typically >50% area reduction in 4 weeks predicts successful healing

Healing trajectory monitors whether wound area is reducing at the expected rate — less than 50% reduction in 4 weeks suggests the treatment plan needs revision.

Healing trajectory is a clinical concept in modern wound management: if a wound is receiving appropriate treatment (debridement, infection control, moisture balance, compression, offloading), it should reduce in area by approximately 20–40% per 2 weeks (or 50% in 4 weeks). Studies show that venous ulcers not demonstrating ≥50% area reduction at 4 weeks have a low probability of healing in 12 weeks with standard care alone, and warrant escalation (specialist referral, advanced wound care products, NPWT, cellular and tissue-based products). Wound area measurement using digital wound imaging or structured photography improves tracking accuracy and objective reassessment. Trajectory monitoring prevents prolonged ineffective treatment.

Question 25: Which of the following is a contraindication to applying compression bandaging for a venous leg ulcer?

Significant arterial insufficiency (ABPI < 0.6) (Correct answer)
A venous ulcer larger than 5 cm in diameter
Age over 80 years
Presence of light exudate

Correct answer: Significant arterial insufficiency (ABPI < 0.6)

Compression is contraindicated in significant arterial disease (ABPI < 0.6) because it can critically reduce already-compromised arterial blood flow to the limb.

Before applying compression therapy for a venous ulcer, ankle-brachial pressure index (ABPI) must be measured: ABPI >0.8 = full compression (25–35 mmHg) is safe; ABPI 0.6–0.8 = modified/reduced compression may be used with caution and vascular input; ABPI <0.6 = significant arterial disease — compression is contraindicated (risk of tissue ischaemia and limb loss); ABPI >1.3 = calcified vessels (often in diabetics) — unreliable reading, requires specialist assessment. Absolute contraindications to compression include: ABPI <0.6, decompensated cardiac failure (compression worsens fluid overload), deep vein thrombosis (consult vascular), acute cellulitis (treat infection first), and undiagnosed limb pathology. Unna's boot or modified compression may be appropriate with vascular specialist guidance for borderline ABPI.

Question 26: Which wound assessment finding requires immediate escalation to a senior clinician?

Rapidly spreading cellulitis with systemic sepsis signs (fever, tachycardia, hypotension) or crepitus suggesting gas-forming bacteria (necrotising fasciitis) (Correct answer)
A small increase in wound exudate volume
Mild wound discolouration at a surgical site on day 3
Yellow slough requiring autolytic debridement

Correct answer: Rapidly spreading cellulitis with systemic sepsis signs (fever, tachycardia, hypotension) or crepitus suggesting gas-forming bacteria (necrotising fasciitis)

Necrotising fasciitis and sepsis secondary to wound infection are life-threatening surgical emergencies — crepitus, rapidly spreading erythema, systemic instability, and severe pain or paradoxically reduced pain require immediate escalation.

Necrotising fasciitis (NF) is a rapidly progressive, life-threatening bacterial infection of the fascia and subcutaneous tissue with 25–35% mortality even with optimal treatment. Cardinal features: severe disproportionate pain (early) or paradoxically reduced pain (late, as nerves are destroyed), rapidly spreading erythema and oedema beyond initial wound margins, crepitus (gas in tissue from gas-forming organisms — Clostridia), skin blistering or necrosis, systemic sepsis (fever, tachycardia, hypotension, altered consciousness). Management is a surgical emergency: wide surgical debridement within hours, IV antibiotics, ICU support. Any wound demonstrating crepitus, rapid spread, or systemic instability requires immediate escalation — this is a potential OSCE safety station designed to test recognition of this emergency.

OSCE OSCE Wound Care and Dressings

When assessing a wound in an OSCE, which mnemonic is commonly used to structure wound assessment documentation?

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