Exam 3 part 2

Question 1

what is the order of the skin from top to inside?

Answer 1

epidermis and dermis

Question 2

what does skin do?

Answer 2

protects from infection
locks in moisture
protects from uv
vitamin d production
absorbs medication

Question 3

how does skin change with age?

Answer 3

as you get older you
decrease in collagen production
decresed circulation
dehydration
slower cell replication

Question 4

what factors affect skin integrity

Answer 4

occupation….healt status…diabetes…circulation issues…decreased oil production….immuno comprimised

Question 5

what is a wound?

Answer 5

any break in the skin

Question 6

what promotes faster wound healing?

Answer 6

nutrition…hand hygeine…blood supply

Question 7

what are some local factors that can affect healing?

Answer 7

location….desacation….masceration…repeated trauma…edema..infection…bleeding..necrosis…eschar

Question 8

what is desecation?

Answer 8

drying up of skin

Question 9

what is masceration?

Answer 9

overhydration

Question 10

what are some systemic factors that affect healing?

Answer 10

circulation problems…smoking….nutrition….meds….anemic… radiation…chemo meds…prolonged antibiotics…

Question 11

how long does it take for infection to set in a wound?

Answer 11

2-7 days

Question 12

what are signs and symptoms of infection?

Answer 12

increased temp….increased WBC…increased drainage…increased pain

Question 13

what is hemorrhaging wound mean?

Answer 13

can be caused by stich opening up or infection

Question 14

what does dehissence mean?

Answer 14

wound has opened up and muscle tissues is visiable

Question 15

what does visceration mean?

Answer 15

muscle and oragns are visible

Question 16

what should you do when dehiscence and evisceration occur?

Answer 16

put on sterile saline and call provider?

Question 17

which one calls for immediate surgery dehiscence and evisceration?

Answer 17

evisceration

Question 18

what are you looking for in wound assessment?

Answer 18

apperance….size…depth…drain…sutures, staples, glue..drainage color/smell

Question 19

what is serous fluid?

Answer 19

clear fluid

Question 20

what is sangionus fluid?

Answer 20

bloody fluid

Question 21

what is serosanguinous fluid?

Answer 21

mix of blood and clear

Question 22

what is purulent fluid?

Answer 22

infection….green

Question 23

what does malodorous mean?

Answer 23

bad smell

Question 24

what is a pressure injury?

Answer 24

bed sore caused by pressure….pressure leads to less ciruclation

Question 25

what is friction?

Answer 25

the force of rubbing two surfaces against one another.

Question 26

what is shearing?

Answer 26

pressure from and object

Question 27

who is at risk for pressure injury/

Answer 27

immobile…bed rest…poor nutrition…overly hydrated….dehydrated…altered LOC…coma

Question 28

what are the characteristics of a stage 1 pressure injury?

Answer 28

localized redness…..non blanch-able skin

Question 29

what are the characteristics of a stage 2 pressure injury?

Answer 29

partial skin broken…blisters

Question 30

what does non blanchable mean?

Answer 30

if pressed wont turn white when pressed

Question 31

what are the characteristics of a stage 3 pressure injury?

Answer 31

broken skin…could have tunneling…

Question 32

what are the characteristics of a stage 4?

Answer 32

bone and tendon showing….tunnnleing

Question 33

what is the braden scale?

Answer 33

assesses fall risk in patients

Question 34

what is the braden scale ranges

Answer 34

Risk 18 and belwo
No Risk: Total Score 19-23.

Question 35

what braden scale number calls for intervention?

Answer 35

18 and below