integ

Question 1

epidermis

Answer 1

keratinocytes, melanocytes, Langerhans Cells, Basal Cells

Question 2

dermis

Answer 2

collagen, retinaculum, fibroblasts, macrophages, lymphatic glands, blood vessels, nerve fibers

Question 3

primary function of integ system

Answer 3

protection, insulation, holding organs tg, sensory, fluid balance, temp control, absorbing UV radiation, metabolizing Vitamin D, synthesizing epidermal lipids

Question 4

Pacinian corpuscles function

Answer 4

starts from P as pressure

detect deep pressure and vibration

Question 5

meissners corpuscles function

Answer 5

detect light touch and texture

Question 6

merkel disks function

Answer 6

detect light touch, texture and pressure

Question 7

Ruffini endings function

Answer 7

detect warmth, stretch, deformation within joints

Question 8

free nerve endings function

Answer 8

detect pain, temp, touch, pressure, tickle and itch

Question 9

Krause end bulb function

Answer 9

detect cold temperature

Question 10

skin conditions: herpes zoster

Answer 10

aka shingles
has initial symptoms of pain and paresthesia localized to the affected dermatome

present as painful rash with clusters of fluid filled vesicles
mostly unilateral
raised to palpation <2mm
pink with silvery white appearance

Question 11

venous insufficiency

Answer 11

refers to inadequate drainage of venous blood from a body part, usually resulting in edema and/or skin abnormalities and ulcerations

Question 12

arterial insufficiency

Answer 12

refers to a lack of adequate blood flow to a region of the body

Question 13

clinical presentation of venous insufficiency

Answer 13

proximal to medial malleolus
irregular, shallow appearance
flaking, brownish discoloration - hempsiderin staining
wet wound
mild to mod pain
elevation decreases pain

Question 14

clinical presentation of arterial insufficency

Answer 14

lower 1/3 leg, tow, dorm of foot, lateral malleolus
smooth edges, well defined, tend to be deep
thin and shiny, hair loss, yellow nails, dry skin
intermittent claudication
elevation increases pain

Question 15

stage 1. pressure ulcer

Answer 15

intact skin with non-blanch able redness

Question 16

stage 2 pressure ulcer

Answer 16

partial thickness wound, superficial in nature with pink/red wound bed (shallow crater)

Question 17

stage 3 pressure ulcer

Answer 17

full thickness wound. subcutaneous fat tissue visible but no bone, tendon and muscle exposed (deep crater). slough/eschar present. undermining and tunneling may occur

Question 18

stage 4 pressure ulcer

Answer 18

full thickness with exposed bone, tendon or muscle. slough/eschar present. undermining and tunneling often occur

Question 19

unstageable pressure ulcer

Answer 19

wound bed covered with slough/eschar (unable to identify depth)

Question 20

deep tissue injury

Answer 20

intact skin purple maroon appearance

Question 21

diabetic ulcer

Answer 21

generally located on WB surface of foot

Question 22

wound examination

Answer 22

measure LxWxD
granulation tissue - viable
necrotic tissue - non-viable
wound drainage and color
edges: thin or thick (indurated), rolled (epibole)
periwound - surrounding the wound

Question 23

maceration

Answer 23

if a wound is too moist, the edges and periwound will become macerated

it is identified as white, friable, over hydrates and sometimes wrinkled skin

cause: inappropriate wound care, uncontrolled wound drainage, perspiration or incontinence

Question 24

desiccation

Answer 24

if a wound lacks moisture, the wound and periwound will become desiccated

identified as cracked, with dry or flakey edges, and the tissue within wound bed may be hard or crusty

cause - inappropriate wound care, inadequate moisture, infection, dehydration

Question 25

selective debridement

Answer 25

removal of only nonviable tissues from a wound

Question 26

sharp debridement

Answer 26

use of scaple, scissors or forceps

Question 27

enzymatic debridement

Answer 27

use of a tropical application of enzymes

Question 28

autolytic debridement

Answer 28

use of the body own mechanism to remove nonviable tissue

Question 29

nonselective debridement

Answer 29

removal of both nonviable and viable tissues from a wound

Question 30

wet to dry dressings

Answer 30

application of a moistened gauze over an area of necrotic tissue to be completely dried and removed

Question 31

wound irrigation:

Answer 31

moves necrotic tissue from wound bed using pressurized fluid

Question 32

hydrotherapy

Answer 32

using a whirlpool with irrigation directed toward a wound requiring debridement

Question 33

when to use transparent films

Answer 33

ver mild exudate

Question 34

when to use hydrogel dressing and hydrocolloid

Answer 34

minimal exudate

Question 35

when to use foam dressing

Answer 35

moderate exudate

Question 36

when to use calcium alginates, hydrofiber

Answer 36

heavy exudate

Question 37

what to use for dressing on an infected wound

Answer 37

hydrofiber, hydrogel, calcium alginates, and guaze

Question 38

red wound color - management technique

Answer 38

cover the wound, keep it moist and clean and protect it from trauma use a transparent dressing (tegaderm, opsite) over a gauze dressed moistened with normal saline solution, use a hydrogel, foam, or hydrocolloid dressing to insulate and protect the wound

Question 39

yellow wound color - management technique

Answer 39

clean the wound and remove yellow layer cover the wound with a moisture retentive dressing such as hydrogel or foam dressing, or a moist glaze dressing with other without deriding enzyme consider hydrotherapy with whirlpool or pulsatile lavage

Question 40

black wound color - management technique

Answer 40

decried the wound as ordered. use an enzyme product, conservative sharp debridement, or hydrotherapy with whirlpool or pulsate lavage for wounds with inadequate blood supply and non-infected heel ulcers, don't deride. keep them clean and dry