Chapter 32: Skin Integrity

Question 1

4 Processes involved in wound healing

Answer 1

1. hemostasis
2. inflammatory phase
3. proliferation phase
4. maturation phase

Question 2

2 categories of factors that affect wound healing

Answer 2

1. local

2. systemic

Question 3

9 local factors that affect wound healing

Answer 3

1. pressure
2. desiccation
3. maceration
4. trauma
5. edema
6. infection
7. excessive bleeding
8. necrosis
9. biofilm

Question 4

6 systemic factors that affect wound healing

Answer 4

1. age
2. circulation and oxygenation
3. nutritional status
4. wound etiology
5. medications and health status
6. Immunosuppression

Question 5

6 factors placing person at risk for skin alterations

Answer 5

1. Age
2. Lifestyle variables (homosexuality, IV drug use, multple sexual partners, occupation w/ prolonged sun exposure, body piercings)
3. Changes in health state (dehydration, malnutrition, paralysis, local nerve damage, circulatory insufficiency)
4. Illness (diabetes)
5. Diagnostic measures (GI series -diarrhea)
6. Therapeutic measures (bed rest, casts, aquathermia unit, meds, radiation therapy)

Question 6

6 factors to assess in skin assessment

Answer 6

1. Appearance of Skin
2. Recent changes in skin
3. Activity/mobility
4. nutrition
5. pain
6. elimination

Question 7

4 types of wound complications

Answer 7

1. infection
2. hemorrhage
3. dehiscensce and evisceration
4. fistula formation

Question 8

2 factors in Pressure Injury development

Answer 8

1. external pressure

2. friction and shear

Question 9

5 factors placing person at risk for pressure injury development

Answer 9

1. immobility
2. nutrition and hydration
3. moisture
4. mental status
5. age

Question 10

3 pressure injury risk assessment scales

Answer 10

1. Norton Scale
2. Waterlow Scale
3. Braden Scale

Question 11

Hemostasis

Answer 11

Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing

Question 12

Inflammatory Stage

Answer 12

the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound

Question 13

Proliferative phase

Answer 13

In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization

Question 14

Maturation

Answer 14

Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.

Question 15

Avulsion

Answer 15

tearing of structure from normal anatomic position

Question 16

laceration

Answer 16

tearing of skin with blunt or irregular instrument, tissue not aligned, often with loose flaps of skin

Question 17

possible systemic reactions to wound

Answer 17

increase in temp
increase in HR
increase in resp rate
anorexia
vomiting
musculoskeletal tension
hormonal changes

Question 18

Nutrition and wound healing

Answer 18

Vitamin A - collagen synthesis and epithelializiation
Vitamin B - cofactor of important enzyme reacitons
Vitamin C - collagen synth, capillary formatin, resistance to infeciton
Vitamin K - prothrombin synth
Zinc, copper, iron - collagen synth
Manganese - enzyme activator

Question 19

proliferation phase alternate names

Answer 19

fibroblastic phase
regenerative phase
connective tissue phase

Question 20

connective tissue that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation and increasing number and movement of epithelial cells

Answer 20

fibroblasts

Question 21

epidermal stripping

Answer 21

unintentional removal of epidermis with tape

Question 22

hematoma

Answer 22

localized mass of usually clotted blood

Question 23

risk factors for wound complications

Answer 23

obese
smoking
excessive coughing, vomiting, straining
malnourished
anticoagulants
infection

Question 24

dehiscence and evisceration response

Answer 24

1. low fowlers
2. cover exposed abdominal contents with saline moist sterile towels
3. contact provider immediately
4. NPO

Question 25

with 2 hour repositioning, how long before a reddened area due to reactive hyperemia fades

Answer 25

60-90 minutes

Question 26

what stage would a large intact serum filled blister be

Answer 26

stage 2

Question 27

Focused critical thinking guide

Answer 27

1. identify goal of thinking 2. asses adequacy of knowledge - pertinent circumstances - prerequisite knowledge - room for error - time constraints 3. Address potential problems 4. consult helpful resources 5. Critique judgement/decision

Question 28

Focused skin assessment

Answer 28

1. appearnce of skin 2. recent changes in skin 3. activity/mobility 4. nutrition 5. pain 6. elimination

Question 29

skin assessment based on setting

Answer 29

acute care: on admission, reassess every shift and with any change in condition long-term care: on admission then reassess weekly for 4 weeks, then quarterly and whenever condition changes Home health care: on admission, then reassess at every visit

Question 30

T-tube

Answer 30

T-shaped tube placed in common bile duct,, collects bile after gallbladder surgery

Question 31

Braden scale

Answer 31

1. mental status 2. continence 3. mobility 4. activity 5. nutrition

Question 32

autolytic debridement

Answer 32

uses occlusive dressings, such as hydrocolloids, or transparent films, uses body's own enzymes