chapter 32

Question 1

factors that effect skin integrity

Answer 1

age
the amount of underlying tissue
illness conditions

Question 2

what is a wound

Answer 2

a break or disruption in the normal integrity of the skin and tissues

Question 3

how does wound repair occur

Answer 3

primary intention
secondary intention
tertiary intention

Question 4

what is a primary intention

Answer 4

minimal tissue loss

Question 5

what is a secondary intention

Answer 5

the wound has edges that are not well approximated
require more tissue replacement
take longer to heal

Question 6

the tertiary intention

Answer 6

delayed primary closure

left open for several days to allow edema or infection resolve for fluid to drain and then are closed

Question 7

what are the phases of wound healing

Answer 7

phase one: hemostasis
phase two: inflammatory response
phase three: proliferation phase
phase four: maturation phase

Question 8

what is a scar

Answer 8

an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

Question 9

what is phase one: hemostasis

Answer 9

occurs immediately after the initial injury

blood vessels involved constrict to allow blood clotting to be through the platelet activation and clustering

Question 10

what is phase two inflammatory response

Answer 10

follows hemostasis and lasts about 2 to 3 days
WBC move to the wound
leukocytes arrive first to ingest bacteria
then macrophages 24 hours after

Question 11

what is what three proliferation phase

Answer 11

lasts for several weeks

new tissue is built to kill wound space, through the action of fibroblasts

Question 12

what is the phase for maturation phase

Answer 12

the final stage of healing
begins about 3 weeks after the injury - continues for months or years
collagen deposited
new collagen is still deposited and compressing blood vessels and forming a scar

Question 13

infection

Answer 13

patients immune systems fail to control the growth of microorganisms

Question 14

hemorrhage

Answer 14

slipped suture, a dislodged clot at a wounds site, infection or erosion of a blood vessel by a foreign body

Question 15

dehiscence

Answer 15

partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

Question 16

evisceration

Answer 16

a complication of dehiscence. occurs in the abdominal it completely separates, with protrusion of viscera through the incisonal area

Question 17

fistula

Answer 17

the abnormal passage from an internal organ or vessel to the outside of the body

Question 18

what is a pressure ulcer (pressure injury)

Answer 18

localized damage to the skin and underlying tissue that usually occurs over a bony prominence

Question 19

what are factors in pressue injury development

Answer 19

external pressure

friction and shear

Question 20

what are common supine position bony prominences

Answer 20

occipital bone
scapula
vertebrae
sacrum
coccyx
calcaneus

Question 21

what are common prone position bony prominences

Answer 21

frontal bone
mandible
humerus
sternum
tuberosity of pelvis
patella
tibia

Question 22

what are common sims positions bony prominences

Answer 22

scapula
ribs
iliac crest
greater trochanter of femur
lateral knee
lateral malleolus
medial malleolus

Question 23

what are the risks for pressure injuries

Answer 23

Aging skin
Vascular disorders
Obesity
Immobility and incontinence
Diabetes
Skin friction
Poor nutrition
Reduced RBC's (anemia)
Edema
Sensory deficits
Sedation

Question 24

what are the warning signs of a pressure ulcer

Answer 24

blanching of skin

skin can feel warm

Question 25

what is the Braden scale

Answer 25

assess patients for pressure ulcers low risk: 22-23 less risk: 19-21 high risk: < 18

Question 26

what is a type one pressure ulcer

Answer 26

skin is intact nonblanchable redness swollen tissue darker skin - may appear blue/purple

Question 27

what is a type two pressure ulcer

Answer 27

``` partial-thickness epidermis and the dermis superficial ulcer abrasion or ulcer - no fatty tissue is visible ```

Question 28

what is a type three pressure ulcer

Answer 28

``` full-thickness SKIN loss damage to necrosis or subcut tissue no exposed muscle or bone ulcer extended down to the underlying fascia but not through it deep crater without tunneling ```

Question 29

what is a type four pressure ulcer

Answer 29

full-thickness TISSUE loss destruction of tissue damage to muscle and bone deep pockets of infection and tunneling

Question 30

what is an unstageable pressure ulcer

Answer 30

when the stage cannot be determined due to eschar or slough covering the visibility of the wound making the depth unknown.

Question 31

prevention of pressure ulcers

Answer 31

relive pressure proper nutrition skin hygiene repositioning

Question 32

what is a skin assessment

Answer 32

inspection and palpation used to assess the integumentary system