Skin Integrity

Question 1

list some functions of the skin

Answer 1

• Protects against disease causing organisms
• Sensory organ for temperature, pain, and touch
• Synthesizes Vitamin D
• Injury to skin poses a risk to safety and triggers a complex healing process

Question 2

factors affecting skin

Answer 2

• Genetics and heredity
• Age
• Chronic illnesses and their treatments
• Medications
• Poor nutrition

Question 3

outer and top layer of the skin that you can see and touch

Answer 3

epidermis

Question 4

protein inside skin cell

Answer 4

keratin

Question 5

inner layer of skin

Answer 5

dermis

Question 6

what is the function of the epidermis

Answer 6

functions to resurface wounds & restore the barrier against bacteria

Question 7

what is the function of the dermis

Answer 7

functions to restore structural integrity-collagen & physical properties of skin

Question 8

list the types of wounds

Answer 8

open wounds
closed wounds
ulcers

Question 9

list types of open wounds

Answer 9

abrasion
laceration
puncture
avulsion

Question 10

This kind of wound is not deep, so there is little to no bleeding that occurs

Answer 10

abrasion

Question 11

deep and jagged cut that results in skin tears and heavy bleeding

Answer 11

laceration

Question 12

hole-shaped wounds caused by pointy objects such as needles and nails

Answer 12

puncture

Question 13

severe wound that can result in the partial or complete tear of the skin and tissues

Answer 13

avulsion

Question 14

list types of closed wounds

Answer 14

contusions
blisters
seroma
hematoma
crush injury

Question 15

happens when small blood vessels get torn and leak blood under the skin

Answer 15

contusion

Question 16

bubbles that pop up when fluid collects in pockets under the top laver of your skin

Answer 16

blisters

Question 17

accumulation of clear fluid under the skin, typically near the site of a surgical incision

Answer 17

seroma

Question 18

pool of mostly clotted blood that forms in an organ, tissue, or body space

Answer 18

hematoma

Question 19

result of physical trauma from prolonged compression of the torso, limb(s), or other parts of the body

Answer 19

crush injury

Question 20

list types of ulcers

Answer 20

pressure
venous
arterial
neuropathic

Question 21

Injury to skin and/or underlying tissue usually over a bony prominence

Answer 21

pressure injuries

Question 22

Deficiency in blood supply to tissue

Answer 22

ischemia

Question 23

Bright red flush to skin when pressure is received

Answer 23

reactive hyperemia

Question 24

Extra blood floods to compensate for preceding period of impeded blood flow

Answer 24

vasodilation

Question 25

trauma caused by tissue lavers sliding across each other, results in disruption or angulation of blood vessels

Answer 25

shear

Question 26

what are the common pressure sites within the supine position

Answer 26

heels sacrum (tailbone) scapulae (shoulder) back of head

Question 27

what are the common pressure sites of the lateral position

Answer 27

malleolus (ankle) knee ilium (hips) shoulder ear side of head

Question 28

what are the common pressure sites within the prone position

Answer 28

toas knees genitalia (men) breasts (women) shoulder (acromial process) cheek and ear (zygomatic bone)

Question 29

what are the common pressure sites within the fowlers position

Answer 29

heels (calcaneus) buttocks sacrum ball of foot pelvis vertebrae

Question 30

Intact skin with non-blanchable redness or erythema of a localized area usually over a bony prominence. Darkly pigmented skin may not have blanching: its color may differ from the surrounding area What stage of pressure ulcer is this

Answer 30

stage 1

Question 31

list stage 1 pressure ulcer treatment

Answer 31

* Off-load pressure * Transparent film dressing * Hydrocolloid dressing * Moisture barrier

Question 32

Partial thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow open ulcer. Presents as shiny or shallow ulcer red/ pink wound bed) without slough or bruising what stage of pressure ulcer is this

Answer 32

stage 2

Question 33

list stage 2 pressure ulcer treatments

Answer 33

hydrocolloid dressing absorptive dressing hydrogel off-load pressure

Question 34

Full thickness skin loss involving damage or necrosis to subcutaneous tissue that may extend down to, but not through underlying fascia. Ulcer presents as a deep crater with or without undermining or tunneling of adjacent tissue what stage of pressure ulcer is this

Answer 34

stage 3

Question 35

list stage 3 pressure ulcer treatments

Answer 35

* Requires physician order for Stage Ill or * Draining vs. Non-draining * Necrotic vs. Granulating * Draining wounds.-Absorptive dressings * Granulating wounds..*Hydrogel * Necrotic wounds-Require debridement (Chemical. Mechanical, Autolytic, Sharp

Question 36

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures. Exposed bone or tendon is visible or directly palpable what stage of pressure ulcer is this

Answer 36

stage 4

Question 37

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in the wound bed. The true depth of the wound cannot be determined until slough or eschar is removed what is this referred as

Answer 37

unstageable wound

Question 38

types of wound healing

Answer 38

primary intention secondary intention tertiary intention

Question 39

* Tissue surfaces approximated (closed) with sutures * Minimal or no tissue loss * Formulation of minimal granulation tissue and scarring healing by which intention

Answer 39

primary intention

Question 40

* Extensive tissue loss * Edges cannot be approximated. * Repair time is longer. * Scarring is greater. * Susceptibility to infection is greater healing by which intention

Answer 40

secondary intention

Question 41

* Also known as delayed primary intention * Initially left open 3-5 days * Edema, infection to resolve, or exudate to drain * Closed with sutures, staples, or adhesive skin closures healing by which intnetion

Answer 41

tertiary intention

Question 42

list phases of wound healing

Answer 42

inflammatory phase proliferative phase maturation phase

Question 43

list complications of wound healing

Answer 43

hemorrhage infection dehiscence with possible evisceration

Question 44

list factors affecting wound healing

Answer 44

* Developmental considerations * Nutrition * Lifestyle * Medications

Question 45

types of exudates

Answer 45

* Serous * Purulent * Sanguineous * Mixed Exudates

Question 46

* Mostly serum * Derived from blood and serous membranes of the body * Looks watery, few cells

Answer 46

Serous Exudates

Question 47

* Thicker * Presence of pus * Consists of leukocytes, liquified dead tissue debris, dead and living bacteria * Color varies with causative organism

Answer 47

Purulent exudate

Question 48

* Large number of RBCs * Indicates severe damage to capillaries * Frequently seen in open wounds

Answer 48

Sanguineous exudate

Question 49

mixed exudate is composed of what

Answer 49

Serosanguineous Purosanguineous

Question 50

Clear and blood-tinged drainage

Answer 50

Serosanguineous

Question 51

Pus and blood

Answer 51

Purosanguineous

Question 52

dry, leathery, black or brown

Answer 52

Eschar

Question 53

stringy, cheesy, loose, yellow, tart

Answer 53

Slough

Question 54

healthy, viable pink to beefy red

Answer 54

Granulation

Question 55

occurs along wound edges or as islands inside wound bed, pale pink resurfacing of wound

Answer 55

Epithelialization

Question 56

may mean infection

Answer 56

Erythema

Question 57

Whitish, wrinkled appearance

Answer 57

Maceration

Question 58

Macular or papular, may indicate fungal infection

Answer 58

Rash