Skin Integrity

Question 1

The appearance of the skin and skin integrity are influenced by internal factors such as GENETICS, AGE, and the UNDERLYNG HEALTH of the individual as well as external factors such as ACTIVITY.

Question 2

Types of Wounds

a. _____ occurs during therapy.
- Although removing a tumor, for example, is therapeutic, the surgeon must cut into body tissues, thus traumatizing them.

b. _____ are accidental
- for example, a person may fracture an arm in an automobile collision.

c. _____ - If the tissues are traumatized without a break in the skin

d. _____ - when the skin or mucous membrane surface is broken.

Answer 2

Intentional trauma
Unintentional wounds
Closed wound
Open wound

Question 3

According to the likelihood and degree of wound contamination.

1. _____ are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. It is primarily closed wounds.
2. _____ are surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered. Such wounds show no evidence of infection.
3. _____ 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. It shows evidence of inflammation.
4. _____ include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.

Answer 3

Clean wounds
Clean-contaminated wounds
Contaminated wounds
Dirty or infected wounds

Question 4

Classifying Wounds by Depth

_____: confined to the skin, that is, the dermis and epidermis; heal by regeneration.

_____: involving the dermis, epidermis, subcutaneous tissue, and possibly.

Answer 4

Partial thickness
Full thickness

Question 5

Types Of Wound

_____ 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.

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

_____ Open wound involving

_____ Open wound

_____ Open wound; edges often jagged(e.g., with machinery).

_____ Open wound tissues, usually unintentional (e.g., from a bullet or metal fragments).

Answer 5

Incision
Contusion
Abrasion the skin
Puncture
Laceration
Penetrating

Question 6

_____ 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.

• were previously called decubitus ulcers, pressure sores, or bedsores.

Answer 6

Pressure ulcers

Question 7

a deficiency in the blood supply to the tissue.

Answer 7

Localized ischemia

Question 8

10 Risk Factors

1. _____ a force acting parallel to the skin surface.
   - _____ is a combination of friction and pressure.
2. _____ refers to a reduction in the amount and control of movement a person has.
3. _____ causes weight loss, muscle atrophy, and the loss of subcutaneous tissue.
4. _____

Answer 8

1. FRICTION AND SHEARING
   - Shearing force
2. IMMOBILITY
3. INADEQUATE NUTRITION
4. FECAL AND URINARY INCONTINENCE
5. DECREASED MENTAL STATUS
6. DIMINISHED SENSATION
7. EXCESSIVE BODY HEAT
8. ADVANCED AGE
9. CHRONIC MEDICAL CONDITIONS
10. Poor lifting and transferring techniques, incorrect positioning, hard support surfaces, and incorrect application of pressure-relieving devices.

Question 9

RISK ASSESSMENT TOOLS

A. _____ for Predicting Pressure Sore Risk
➢ consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear
➢ A total of 23 points is possible and an adult who scores below 18 points is considered at risk

B. _____
➢ It includes the categories of general physical condition, mental state, activity, mobility, and incontinence.

c. A category of medications is added by some users, resulting in a possible score of 24. Scores of 15 or 16 should be viewed as indicators, not predictors, of risk.

Answer 9

Braden Scale

Norton’s Pressure Area Risk Assessment Form (Scoring System)

Question 10

_____ is a quality of living tissue; it is also referred to as regeneration (renewal) of tissues.

Answer 10

Healing

Question 11

Types of Wound Healing

1. _____: occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring.
   ➢ It is also called primary union or first intention healing.
2. _____: a wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated.
3. _____: wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by tertiary intention.

Answer 11

1. Primary intention healing
2. Secondary intention healing
3. Delayed primary intention

Question 12

Phases of Wound Healing
➢ Wound healing can be broken down into three phases:
1. Inflammatory
2. Proliferative
3. Maturation or remodelling.

Question 13

Phases of Wound Healing

1. The _____ begins immediately after injury and lasts 3 to 6 days. Two major processes occur during this phase (Hemotastasis and Phagocytosis)
2. _____ Extends from day 3 or 4 to about day 21 post injury. Fibroblasts (connective tissue cells), which migrate into the wound starting about 24 hours after injury, begin to synthesize collagen.
3. _____ begins on about day 21 and can extend 1 or 2 years after the injury. Fibroblasts continue to synthesize collagen.

Answer 13

INFLAMMATORY PHASE
PROLIFERATIVE PHASE
MATURATION PHASE

Question 14

_____ is a whitish protein substance that adds tensile strength to the wound.

Answer 14

Collagen

Question 15

Types of Wound Exudate

______ consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum. It looks watery and has few cells.

_____ thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria. The process of pus formation is referred to as SUPPURATION.

_____ 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. This type of exudate is frequently seen in open wounds.

Answer 15

serous exudate
purulent exudate
sanguineous exudate

Question 16

Complications of Wound Healing

1. _____ (massive bleeding)
2. _____ Contamination of a wound surface with microorganisms (colonization).
3. _____ the partial or total rupturing of a sutured wound. More likely to occur 4 to 5 days postoperatively before extensive collagen is deposited in the wound.

Answer 16

HEMORRHAGE
INFECTION
DEHISCENSE

Question 17

Factors Affecting Wound Healing

1. DEVELOPMENTAL CONSIDERATIONS
2. NUTRITION
3. LIFESTYLE
4. MEDICATIONS

Question 18

Client Teaching about Skin Integrity
MAINTAINING INTACT SKIN

• Discuss relationship between adequate nutrition (especially fluids, protein, vitamins B
  and C, iron, and calories) and healthy skin.
• Demonstrate appropriate positions for pressure relief.
• Establish a turning or repositioning schedule.
• Demonstrate application of appropriate skin protection agents and devices. * Instruct to report persistent reddened areas.
• Identify potential sources of skin trauma and means of avoidance.

Question 19

PROMOTING WOUND HEALING

• Discuss importance of adequate nutrition (especially fluids, protein, vitamins B and C,
  iron, and calories).
• Instruct in wound assessment and provide mechanism for documenting.
• Emphasize principles of asepsis, especially hand hygiene and proper methods of
  handling used dressings.
• Provide information about signs of wound infection and other complications to report. * Reinforce appropriate aspects of pressure ulcer prevention.
• Demonstrate wound care techniques such as wound cleansing and dressing changing. * Discuss pain control measures, if needed.