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Student ID No: 57254313031 Student IC No: 820504-08-6244 Programme: BACHELOR OF NURSING

ROYAL COLLEGE OF MEDICINE PERAK

FORMATIVE TEST JULY 2013 SEMESTER

SUBJECT CODE SUBJECT TITLE LEVEL TIME / DURATION DATE : : : : : RNB10404 WOUND AND PAIN MANAGEMENT BACHELOR OF SCIENCE NURSING (HONOURS) (POST REGISTRATION) ONE (1) WEEK 2 7 SEPTEMBER 2013

ANSWER SCRIPT
INSTRUCTIONS TO CANDIDATES
1. Type your student ID No., IC No., and Programme name on the top left of this answer script. 2. Please type your answers in the box provided and email to hychen@rcmp.unikl.edu.my latest by 7 September 2013, 12.00 MN.

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PART 1: SHORT ANSWER QUESTION (SAQ) 1. List FOUR (4) structures of the dermis and describe its functions. [4 marks] Type your answer below
Structure Blood Vessels Function 1.Supply the skin with fresh blood,which contains nutrients and oxygen,and carry away waste products. 2.Help regulate body temperature Sebaceous glands 1. Maintaining the epidermal permeability barrier, structure and differentiation. 2. Transporting antioxidants to the skin surface. 3. Protection from UV radiation. Sensory nerve endings Sweat Glands 1. Sensitive to pain, itchiness and temperature changes. 1.Producing structures consisting of a single tube,a coiled body and a superficial duct.

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2. Differentiate primary and secondary intention of wound healing. [4 marks] Type your answer below
Primary Occur in wounds that have minimal tissue loss The edges that are well approximated (closed) Secondary Occur in wound with extensive tissue loss and wound The edges cannot be approximated. Granulation results in a broader scar

Minimal scarring.

Types 0f wound heal :surgical incisions and first degree burns

Pressure areas,burn,and traumatic wounds

3. State the characteristics for the following elements in wound assessment. [6 marks]
a. Size / wound margin b. Depth c. Nature of wound bed d. Condition of the surrounding skin e. Nature of exudates f. Pain Length , width , well defined Shallow, deep Colour,sensation,granulating, epithelializing, sloughy, necrotic, hypergranulating. Healthy, macerated,desiccated, oedema thickness, amount,colour, consistency, odour Persistent , temporary,infection

4. State ONE (1) effect of the following nutrients in the wound healing process.
[4 marks] a. Carbohydrates Provide energy - To prevent the body from using other nutrients and protein for energy. b. Fats c. Vitamin A Essential for cell membranes. Required for the absorption and function of fat soluble vitamins. Help fight off infection and controlling the inflammatory response. Help body synthesize protein and develop collagen.

d. Zinc

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5. State ONE (1) indication for the following types of dressing products. [3 marks]
a. Films b. Hydrogels c. Hydrocolloids Wound with low exudate For necrotics or sloughy wound Low to moderate exuding wound

6. State FOUR (4) goals for wound management. [4 marks]

Type your answer below 1.Remove necrotic tissue to promote wound healing 2.Prevent,eliminate or control infection 3.Maintain moist wound environment 4.Protect the wound from further injury

PART 2: ESSAY QUESTION 1. Explain FOUR (4) major phases of wound healing (the wound healing cascade). (200-300 words) Type your answer below
Hemostasis: Once the source of damage to a house has been removed and before work can start, utility workers must come in and cap damaged gas or water lines. So too in wound healing damaged blood vessels must be sealed. In wound healing the platelet is the cell which acts as the utility worker sealing off the damaged blood vessels. The blood vessels themselves constrict in response to injury but this spasm ultimately relaxes. The platelets secrete vasoconstrictive substances to aid in this process but their prime role is to form a stable clot sealing the damaged vessel. Under the influence of ADP (adenosine diphosphate) leaking from damaged tissues the platelets aggregate and adhere to the exposed collagen. They also secrete factors which interact with and stimulate the intrinsic clotting cascade through the production of thrombin, which in turn initiates the formation of fibrin from fibrinogen. The fibrin mesh strengthens the platelet aggregate into a stable hemostatic plug. Finally platelets also secrete cytokines such as plateletderived growth factor (PDGF), which is recognized as one of the first factors secreted in initiating subsequent steps. Hemostasis occurs within minutes of the initial injury unless there are underlying clotting disorders.

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InflammationPhase: Clinically inflammation, the second stage of wound healing presents as erythema, swelling and warmth often associated with pain, the classic rubor et tumor cum calore et dolore. This stage usually lasts up to 4 days post injury. In the wound healing analogy the first job to be done once the utilities are capped is to clean up the debris. This is a job for non-skilled laborers. These non-skilled laborers in a wound are the neutrophils or PMNs (polymorphonucleocytes). The inflammatory response causes the blood vessels to become leaky releasing plasma and PMNs into the surrounding tissue. The neutrophils phagocytize debris and microorganisms and provide the first line of defense against infection. They are aided by local mast cells. As fibrin is broken down as part of this clean-up the degradation products attract the next cell involved. The task of rebuilding a house is complex and requires someone to direct this activity or a contractor. The cell which acts as contractor in wound healing is the macrophage. Macrophages are able to phagocytize bacteria and provide a second line of defense. Proliferative Phase ( Proliferation, Granulation and Contraction) :

The granulation stage starts approximately four days after wounding and usually lasts until day 21 in acute wounds depending on the size of the wound. It is characterized clinically by the presence of pebbled red tissue in the wound base and involves replacement of dermal tissues and sometimes subdermal tissues in deeper wounds as well as contraction of the wound. In the wound healing analogy once the site has been cleared of debris, under the direction of the contractor, the framers move in to build the framework of the new house. Sub-contractors can now install new plumbing and wiring on the framework and siders and roofers can finish the exterior of the house. The framer cells are the fibroblasts which secrete the collagen framework on which further dermal regeneration occurs. Specialized fibroblasts are responsible for wound contraction. The plumber cells are the pericytes which regenerate the outer layers of capillaries and the endothelial cells which produce the lining. This process is called angiogenesis. The roofer and sider cells are the keratinocytes which are responsible for epithelialization. In the final stage of epithelializtion, contracture occurs as the keratinocytes differentiate to form the protective outer layer or stratum corneum. Remodeling or Maturation Phase: Once the basic structure of the house is completed interior finishing may begin. So too in wound repair the healing process involves remodeling the dermal tissues to produce greater tensile strength. The principle cell involved in this process is the fibroblast. Remodeling can take up to 2 years after wounding and explains why apparently healed wounds can break down so dramatically and quickly if attention is not paid to the initial causative factors.

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marks] 2. Explain FIVE (5) systemic factors that negatively influence wound healing. (100-150 words) 4
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[10 marks]
Type your answer below 1) Mechanical stress When a patient is immobile and pressure is exerted locally, especially over a bony prominence, for more than two hours, at a pressure exceeding 30 mm of mercury, localised microvascular ischaemia will occur. This will ultimately lead to tissue destruction both at the surface and deeper into the wound-leading eventually to a pressure ulcer. Equally, shearing forces and friction occur when the tissue below the skin is forced to move while the skin itself is restrained by contact to a surface, such as the bed sheet. This is particularly evident in the patients heels 2) Temperature The optimum temperature for the growth of human cells is 37 degrees centigrade. It is therefore essential to maintain the wound environment at body temperature. A drop in body temperature will lead to peripheral vasoconstriction- affecting the flow of blood through the wound- and it will markedly reduce the activity of growth factors and proteases. Increased body temperature can lead to changes at the wound site increasing the risk of cellular breakdown and limiting the healing process 3) Infection All wounds will have some level of bacterial colonisation, however, this does not mean that the wound is infected. The presence of erythema, discharge, fever, pain with elevated white blood cell count, and sometimes odour, is evidence that the wound is infected. If clinical signs of infection are present, the use of systemic antibiotics is mandatory. If there are no clinical signs of infection there is little reason to use either systemic or topical antibiotics. (eg. the use of topical metronidazole in anaerobic colonised wounds) 4) Systemic medications The effects of systemic medications on the healing wound vary greatly. We commonly see medicines prescribed for a condition which is unrelated to the wound, but may have side effects which could either inhibit or stimulate healing. Medications can therefore be divided into two groups; the stimulatory drugs and the inhibitory drugs. The stimulatory drugs affect the inflammatory response, epithelialisation, fibroblast activity, fibrinolysis, and cell stimulation, whereas the inhibitory medications affect tensile strength, cell activity, capillary proliferation, and fibroplasia. 5) Age

Delayed wound healing in the aged is associated with an altered inflammatory response. A review of the age-related changes in healing demonstrate that every phase of healing undergoes characteristic changes, including enhanced platelet aggregation, increased secretion of inflammatory mediators, delayed infiltration of macrophages and lymphocytes, impaired macrophage function, decrease secretion of growth factors, delayed reepithelialization, delayed angiogenesis, reduced collagen turnover and remodeling, and

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decreased wound strength.

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