Skin integrity and wound care

Question 1

Functions of the skin

Answer 1

Temp regulation
protection
Vitamin d production
psychosocial
sensation
immune
absorb
eliminate

Question 2

Intentional

Answer 2

planned invasive therapy or treatment

surgery, iv, clean cuts with controlled bleeding

Question 3

Unintentional

Answer 3

accidental cuts

Question 4

Open

Answer 4

Trauma that breaks the skin’s surface

Question 5

Closed

Answer 5

Trauma that may cause bleeding but skin is not broken

Question 6

Acute

Answer 6

Surgical incisions usually heal in days to weeks
Edges meet to close skin
Infection risk lessened

Question 7

Chronic

Answer 7

Doesn’t progress through normal sequence of repair
risk of infection increased
Healing time delayed
EX: pressure ulcer

Question 8

Partial thickness

Answer 8

Portion of dermis is intact

Question 9

Full-thickness

Answer 9

Entere dermis, swear glands, and hair follicles are severed

Question 10

Complex

Answer 10

Dermis and underlying subcutaneous fat tissue are damaged

Question 11

Incision

Answer 11

Cutting or sharp instrument, wound edges in close approximation and aligned

Question 12

Contusion

Answer 12

Blunt instrument, overlying skin remains intact with injury to underlying soft tissue possible resultant bruising and/or hematoma

Question 13

Abrasion

Answer 13

Friction, rubbing, or scraping epidermal layers of skin. Top layer abraded

Question 14

Laceration

Answer 14

Tearing of skin and tissue with blunt or irregular instrument, tissue not aligned, often with loose flaps of skin and tissue

Question 15

Puncture

Answer 15

Blunt or sharp instrument puncturing the skin; intentional or accidental

Question 16

Penetrating

Answer 16

Foreign object entering the skin, fragments possible scattered throughout tissue

Question 17

Avulsion

Answer 17

Tearing a structure from normal anatomic position, possible damage to blood vessels, nerves and other structures

Question 18

Chemical

Answer 18

Toxic agents such as drugs, acids, alcohols, metals

Question 19

Thermal

Answer 19

high/low temperatures

Question 20

Irridation

Answer 20

UV light or radiation

Question 21

Pressure ulcers

Answer 21

Compromised circulation due to pressure or pressure combined with friction

Question 22

Venous ulcers

Answer 22

Injury and poor venous return

Question 23

Diabetic ulcers

Answer 23

Injury and diabetic neuropathy

Question 24

Hemostasis

Answer 24

Immediately after injury. Involved blood vessels constrict and blood clotting begins

Question 25

Inflammatory phase

Answer 25

4-6 days. White blood cells more in. Leukocytes drive to ingest bacteria and cellular debris. (increase temp, malaise, leukocytes)

Question 26

Proliferation phase

Answer 26

Several weeks - new tissue is build to fill wound space | Fibroblasts

Question 27

Maturation phase

Answer 27

Scarring - approx 3 weeks after injury can continue months to years. Formation of scar tissue

Question 28

Stage 1 ulcer

Answer 28

Intact redness of localized area Non blanch able May be painful, firm, soft, warm/cool May be difficult to detect with dark skin tone

Question 29

Stage 2 ulcer

Answer 29

Partial thickness loss. Red/pink without slough Shinny or dry shallow ulcer

Question 30

Stage 3 ulcer

Answer 30

Full thickness loss, fat visible. Slough present and may tunnel

Question 31

Stage 4 ulcer

Answer 31

Full thickness loss with bone and muscle exposed. Slough or eschar present. Undermining and tunneling

Question 32

Unstageable

Answer 32

full thickness, slough and/or eschar until eschar are removed it is unstageable

Question 33

Infection

Answer 33

when a patients immune system fail to control the growth of microorganisms

Question 34

Hemorrhage

Answer 34

Slipped suture, dislodged clot, infection, or erosion of a blood vessel from a foreign body

Question 35

Dehisence

Answer 35

Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

Question 36

Evisceration

Answer 36

Wound completely separates with protrusion of visceral throughout incisional area

Question 37

Fistula formation

Answer 37

Abnormal passage from internal organ or vessel to outside the body or from one internal organ to another

Question 38

Serous drainage

Answer 38

Clear and watery

Question 39

Sanguineous drainage

Answer 39

blood

Question 40

Serosanguineous

Answer 40

mixture of clear and watery with blood to become pink

Question 41

Purulent

Answer 41

Thick and pussy