Skin Integrity

Question 1

refers to the presence of normal skin and skin layers uninterrupted by wounds.

Answer 1

intact skin

Question 2

Factors affecting skin integrity

Answer 2

genetics
age
illnesses
medications
nutrition

Question 3

Types of wounds

Answer 3

cut
stab
stab and cut
torn
bitten
chopped
crush
hurt
firearms
scalped
surgery
poisoned

Question 4

are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered

Answer 4

clean wounds

Question 5

are surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered.

Answer 5

clean contaminated wounds

Question 6

include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract.

Answer 6

contaminated wounds

Question 7

include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.

Answer 7

dirty or infected wounds

Question 8

Types of Wounds

Answer 8

incision
contusion
abrasion
puncture
laceration
penetrating wound

Question 9

Sharp instrument (e.g., knife or scalpel)

Open wound; deep or shallow; once the edges have been sealed together as a part of treatment or healing, the incision becomes a closed wound

Answer 9

incision wound

Question 10

Blow from a blunt instrument

Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels.

Answer 10

contusion

Question 11

Surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks)

Open wound involving the skin

Answer 11

abrasion

Question 12

Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional

Answer 12

puncture

Question 13

Tissues torn apart, often from accidents

Answer 13

lacerations

Question 14

Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments)

Answer 14

penetrating wound

Question 15

are one of the many signs of nursing home abuse, nursing home neglect, or medical malpractice in a hospital.

Answer 15

bedsores

Question 16

consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement.

Answer 16

pressure ulcers

Question 17

What are the risk factors of pressure ulcers?

Answer 17

friction and shearing
immobility
inadequate nutrition
fecal and urinary incontinence
decreased mental status
diminished sensation
excessive body heat
advance age
presence of certain chronic condition

Question 18

is a force acting parallel to the skin surface.

Answer 18

friction

Question 19

is a combination of friction and pressure. It occurs commonly when a client assumes a sitting position in bed.

Answer 19

shearing force

Question 20

refers to a reduction in the amount and control of movement a person has.

Answer 20

immobility

Question 21

causes weight loss, muscle atrophy, and the loss of subcutaneous tissue.

Answer 21

inadequate nutrition

Question 22

More specifically, inadequate intake of
1.
2.
3.
4.
5.
contributes to pressure ulcer formation

Answer 22

protein
carbohydrates
fluids
zinc
vitamin c

Question 23

Moisture from incontinence promotes skin maceration (tissue softened by prolonged wetting or soaking) and makes the epidermis more easily eroded and susceptible to injury.

Answer 23

fecal and urinary incontinence

Question 24

tissue softened by prolonged wetting or soaking

Answer 24

maceration

Question 25

area of loss of the superficial layers of the skin; also known as denuded area

Answer 25

excoriation

Question 26

Individuals with a reduced level of awareness, for example, those who are unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers because they are less able to recognize and respond to pain associated with prolonged pressure

Answer 26

decreased mental status

Question 27

Paralysis, stroke, or other neurologic disease may cause loss of sensation in a body area.

Answer 27

diminished sensation

Question 28

is another factor in the development of pressure ulcers. An elevated body temperature increases the metabolic rate, thus increasing the cells’ need for oxygen

Answer 28

excessive body heat

Question 29

The aging process brings about several changes in the skin and its supporting structures, making the older person more prone to impaired skin integrity. These changes include the following:

Answer 29

loss of lean body mass Generalized thinning of the epidermis • Decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis • Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands • Diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch • Diminished venous and arterial flow due to aging vascular walls.

Question 30

These conditions compromise oxygen delivery to tissues by poor perfusion and thus cause poor and delayed healing and increase risk of pressure sores.

Answer 30

chronic medical conditions

Question 31

Other factors contributing to the formation of pressure ulcers are 1. 2. 3. 4.

Answer 31

poor lifting and transferring technique incorrect positioning hard support surfaces incorrect application of pressure-relieving devices

Question 32

nonblanchable erythema signaling potential ulceration what stage

Answer 32

stage 1

Question 33

partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis what stage

Answer 33

stage 2

Question 34

full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia

Answer 34

stage 3

Question 35

full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures what stage

Answer 35

stage 4

Question 36

is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.

Answer 36

exudate

Question 37

consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum.

Answer 37

serous exudate

Question 38

is thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria.

Answer 38

purulent exudate

Question 39

The process of pus formation is referred to as

Answer 39

suppuration

Question 40

consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma.

Answer 40

sanguineous exudate

Question 41

consisting of both clear and blood-tinged drainage, is commonly seen in surgical incisions.

Answer 41

serosangioneous exudate

Question 42

discharge, consisting of pus and blood, is often seen in a new wound that is infected.

Answer 42

purosanguineous

Question 43

complications of wound healing

Answer 43

hemorrhage infection dehiscence with possible evisceration

Question 44

is the partial or total rupturing of a sutured wound

Answer 44

dehiscence

Question 45

usually involves an abdominal wound in which the layers below the skin also separate

Answer 45

dehiscence

Question 46

is the protrusion of the internal viscera through an incision.

Answer 46

evisceration

Question 47

a scalpel or scissors is u s e d to separate and remove dead tissue.

Answer 47

sharp debridement

Question 48

removal of the necrotic material

Answer 48

debridement

Question 49

is accomplished through scrubbing force or damp-todamp dressings.

Answer 49

mechanical debridement

Question 50

is more selective than sharp or mechanical techniques. Collagenase enzyme agents such as papainurea are currently most recommended for this use.

Answer 50

chemical debridement

Question 51

dressings such as hydrocolloid and clear absorbent acrylic dressings trap the wound drainage against the eschar

Answer 51

autolytic debridement