Skin Integrity

Question 1

clean wounds

Answer 1

closed, intact, not infected

Question 2

clean-contaminated wounds

Answer 2

surgical wounds - no infection

Question 3

contaminated wounds

Answer 3

open, accidental or surgical - involves major break in sterile technique

Question 4

dirty & infected wounds

Answer 4

show evidence of infection

Question 5

partial thickness wounds

Answer 5

dermis & epidermis healing by regeneration (on its own)

Question 6

full thickness wounds

Answer 6

all 3 layers of tissue - possible muscle & bone - requires tissue repair

Question 7

etiology of pressure wounds

Answer 7

ischemia

Question 8

reactive hyperemia

Answer 8

blanchable bright red flush to skin when pressure removed - results from vasodilation

Question 9

pressure ulcer risk factors

Answer 9

friction & shearing
Immobility
Inadequate nutrition
Incontinence - can cause maceration
Decreased mental status
Diminished sensation
Excessive body heat
Advanced age
Chronic medical conditions

Question 10

stages of pressure ulcers

Answer 10

Stage 1—Nonblanchable erythema
Stage 2—Partial-thickness skin loss - to dermis - open or closed ulcer
Stage 3—Full-thickness skin loss - SQ visible
Stage 4—Full-thickness skin loss c necrosis - muscle, tendon, ligament, bone visible

Question 11

epibole

Answer 11

edges of ulcer roll under & damage to skin extends beneath roll

Question 12

slough and eschar prevent us from…

Answer 12

assessing depth

staging injury

Question 13

Deep tissue pressure injury

Answer 13

Purple or black intact skin - blackish blistered area - heavy or spongy at palpation

Question 14

prevention of pressure ulcers

Answer 14

Assess pt’s risk factors q shift - Braden Scale
Keep skin dry & clean
Use barrier creams
Wrinkle-free linens
Turn q 2 hrs
Watch friction & shear
Special air beds & devices for pts c high risk

Question 15

components of braden scale

Answer 15

sensory perception
moisture
activitiy
mobility
nutrition
friction & shear

Question 16

braden scale explain scores

Answer 16

the higher the score, the less risk for an ulcer

Question 17

Primary intention healing

Answer 17

tissue surfaces approximate - minimal/no tissue loss - minimal granulation tissue & scarring

Question 18

secondary intention healing

Answer 18

extensive tissue loss - no approximation - repair time longer - scarring greater - susceptibility to infection

Question 19

tertiary intention healing

Answer 19

leave wound open for 3-5 days until edema/drainage is gone - closed with sutures, staples, adhesives

Question 20

phases of healing

Answer 20

inflammation
proliferative
maturation

Question 21

dehisence

Answer 21

rupture of sutured wound - partial or total - usually involves abdominal wound c layers beneath skin also separating

Question 22

evisceration

what do you do?

Answer 22

4-5 days post op - protrusion of internal organ through incision - emergency situation - organ is exposed - immediately put on sterile wet dressing, then call physician

Question 23

risk factors for dehisence, evisceration

Answer 23

obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, dehydration

Question 24

assess pressure ulcers for…

Answer 24

location related to bony prominence, undermining or sinus tracts, stage, color of wound bed, location of necrosis or eschar, condition of margins, integrity of surrounding skin, signs of infection

Question 25

minimal drainage

Answer 25

stains dressing - give size of stain

Question 26

moderate drainage

Answer 26

saturates dressing but does not leak out - notify physician

Question 27

maximal drainage

Answer 27

overflow dressing - emergency

Question 28

support wound healing

Answer 28

``` Clean & dress injury using surgical asepsis Do not use alcohol or hydrogen peroxide Obtain C&S if infected Teach pt to move often Provide active or passive ROM exercise RYB color code (color of wound) ```

Question 29

RYB

Answer 29

red - protect yellow - cleanse black - debride

Question 30

4 types of debriding

Answer 30

Sharp - scissors, scalpel to debride wound Mechanical - scrubbing Chemical - enzymes, etc Autolytic - hydrocolloid dressing

Question 31

off loading

Answer 31

devices to prevent ulcers

Question 32

masd

Answer 32

moisture associated skin damage

Question 33

function of wound drains

Answer 33

prevent abscess

Question 34

penrose drain

Answer 34

little tube - drains surgical wounds

Question 35

jackson pratt drain

Answer 35

bulb - squeeze before closing lid - slowly opens and pulls drainage into it

Question 36

hemovac drain

Answer 36

same concept as JP drain, but holds more drainage

Question 37

wound irrigation pressure

Answer 37

4-15 psi

Question 38

type of dressing depends on...

Answer 38

Depends on location, size, type of wound, amount of exudate, whether it requires debridement, is infected, frequency of change, cost, difficulty of application

Question 39

3 types of dressings & what they are used for

Answer 39

Transparent - ulcerations, burns Hydrocolloid - pressure injuries Secure - ensure dressing covers entire wound & doesn’t become dislodged

Question 40

bandage turns & description

Answer 40

Circular - anchor bandages & terminate them - not applied directly to wound Spiral - part of body uniform in circumference Recurrent - cover distal parts of body Figure 8 - elbow, knee, ankle - allow some movement

Question 41

applying arm sling

Answer 41

80º angle arm - thumb facing upward or inward toward body

Question 42

heat causes _______ after 20-30 mins

Answer 42

vasodilation

Question 43

heat increases... | cold decreases...

Answer 43

vasodilation cap permeability inflammation cellular metabolism

Question 44

heat no longer than ___ mins

Answer 44

30

Question 45

heat indications

Answer 45

muscle spasm inflammation pain joint stiffness

Question 46

heat has no effect on

Answer 46

traumatic injuries

Question 47

do not use heat...

Answer 47

``` First 24 hours after traumatic injury Active hemorrhage Noninflammatory edema Skin disorder that causes blister Longer than 30 mins ```

Question 48

maximum cold vasoconstriction

Answer 48

60º

Question 49

lewis hunting effect

Answer 49

alternation of vasodilation & vasoconstriction with cold <60º

Question 50

cold slows _______ | mild _______ effect

Answer 50

bacterial growth | anesthetic

Question 51

cold indications

Answer 51

muscle spasm inflammation pain traumatic injury

Question 52

cold has no effect on

Answer 52

contracture | joint stiffness

Question 53

do not use cold....

Answer 53

Open wounds Impaired circulation Allergy or hypersensitivity to cold

Question 54

rebound phenomenon

Answer 54

occurs at maximum therapeutic effect of hot or cold applications is achieved and the opposite effect begins - Lewis Hunting

Question 55

to know about heat/cold devices

Answer 55

cover them | do not use heat beneath pt