LP4: Integumentary Disorders

Question 1

What is the classification of wounds?

Answer 1

-Intentional (surgical; time is taken to clean the area)

-Unintentional (open wounds)

Question 2

What are the different types of wounds?

Answer 2

-Incision
-Contusion (bruises)
-Abrasion (scrape)
-Laceration
-Avulsion (skin is torn away)
-Puncture (Stepping on a nail)
-Penetrating wound (gun shot, stabbing)

Question 3

What is Partial Thickness?

Answer 3

Affects the dermis and epidermis

Question 4

What is a Full Thickness wound?

Answer 4

Affects the dermis, epidermis, SQ, muscle and bone.

Question 5

What are pressure ulcers?

Answer 5

Any lesión caused by unrelieved pressure that results in damage to underlying tissue.

Question 6

What is the Etiology of pressure ulcers?

Answer 6

Due to localized ischemia (no blood in tissues)
Tissues dies
After skin is compressed it appears pale; when pressure is relieved, a bright red flush appears (reactive hyperemia)

Question 7

What are some Risk Factors for Pressure Ulcers?

Answer 7

-Friction and shearing (skin stays, tissue moves)
-Immobility
-Inadequate nutrition (reduces padding; decreased proteins, fluids, vitC, and Zinc)

Question 8

What is Maceration?

Answer 8

When fecal or urinary incontinence causes tissue to soften

Question 9

What is Excoriation?

Answer 9

When fecal and urinary incontinence cause loss of superficial layer of skin

Question 10

What does Stage I of pressure ulcers consist of?

Answer 10

Red and unopened areas.

Tx:
-Barrier cream
-Cussions
-Reposition
-Protein/ fluids

Question 11

What does Stage II of pressure ulcers consist of?

Answer 11

Open superficial layer of skin.

Tx:
Dressings on

Question 12

What does Stage III of Pressure Ulcers consist?

Answer 12

SubQ layer (fatty) is visible.

Question 13

What’s does stage IV of Pressure Ulcers consist of?

Answer 13

Gets to the muscle and bone

Question 14

What is a Suspected Deep a Tissue Injury?

Answer 14

Purple or maroon localized area of discolored intact skim. May be mushy, boggy warmer/cooler than adjacent skin.

Question 15

What is an Unstageable Pressure Ulcer?

Answer 15

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow dead tissue) or eschar (black dead tissue).

Question 16

What is the EXCEPTION of an Unstageable Ulcer?

Answer 16

When it’s located on the heal and it’s:
-Stable
-Dry
-Eschar is body’s natural cover
-Should not be removed

Question 17

What is the Primary Intention of Wound Healing?

Answer 17

•Tissue surfaces approximated (closed)
•Minimal or no tissue loss
•Surgical incision

Question 18

What is the Secondary Intention of Wound Healing?

Answer 18

•Edges not approximated
•Extensive tissue loss
•Pressure ulcer

Question 19

What is the Tertiary Intention of Wound Healing?

Answer 19

Also know as Delayed Primary Intention

•Wounds are left open for 3-5 days to allow edema or infection to resolve, then are closed with sutures, staples or adhesive skin closure.

Question 20

What is the Inflammatory Phase of the Process of Wound Healing?

Answer 20

Defensive phase (3-6 days)

Hemostasis and phagocytosis

Question 21

What is the Proliferative Phase of the Process of Wound Healing?

Answer 21

Reconstructive phase (4-21 days).

Formation collagen, new blood vessels and tissues, wound closure.

Question 22

What is the Maturation Phase of the Process of Wound Healing?

Answer 22

Scar tissue gains strength. Up to 2yrs.

Question 23

What is PUSH Tool?

Answer 23

Pressure Ulcer Scale for Healing

Assigns scores to the ulcer length, width, amount of exudate (drainage), and tissue type.

Question 24

What are the different kinds of Wound Drainage?

Answer 24

•Serous exudate (watery)
•Purulent exudate (blue, green, or yellow pus)
•Hemorrhagic exudate (blood)
•Serosanguineous exudate (pink color. Watery and bloody drainage)

Question 25

What are some potential complications of wounds?

Answer 25

•Hemorrhage •Infection •Dehiscence (wounds opens up) •Evisceration (wound opens up and organs come out)

Question 26

WhT are some factors that affect wound healing?

Answer 26

•Developmental conditions •Nutrition •Lifestyle •Meds

Question 27

What is the assessment of untreated wounds?

Answer 27

•Assess size & severity •Inspect for bleeding •Inspect for foreign bodies •Assess for other injuries •Check for last tetanus

Question 28

What are the cares for untreated wounds?

Answer 28

•Control severe bleeding •Prevent infection •Control swelling and pain •Assess for shock

Question 29

RYB Wound Classification System

Answer 29

Red, yellow, and black wounds

Question 30

Red wounds consist of:

Answer 30

Color of normal granulation tissue Tx: -Gentle cleansing -Avoid dry gauze -Antimicrobial -Apply transparent film -Change infrequently

Question 31

Yellow wounds consist of:

Answer 31

Fibrinous slough or purulent exudate. Tx: -Cleanse to remove nonviable tissue -Antimicrobial -Hydrocolloid dressing

Question 32

Black wounds consist of:

Answer 32

Contain necrotic (black/eschar) tissue; may be black, gray, brown, or tan. Tx: -Debridement (remove necrotic (black) tissue)

Question 33

What are the Effects of Heat?

Answer 33

-Vasodilation (opens blood vessels) -Increases blood flow -Promotes soft tissue healing -Increase edema and bleeding (shouldn’t be used the first 24hrs after injury)

Question 34

What are the effects of cold?

Answer 34

-Vasoconstriction (good for bruises) -Limits post injury swelling and bleeding -Reduces blood flow (should not be used on open wounds or impaired circulation)