Skin Integrity and Wound Care

Question 1

Skin is the largest:

Answer 1

organ

Question 2

Skin is involved in thermoregulation through its ability to:

Answer 2

dilate and constrict blood vessels

Question 3

The skin has a major tole in sensation by:

Answer 3

giving tactile feedback from the surrounding environment

Question 4

The skins normally acidic pH provides:

Answer 4

a protective mechanism against pathogens

Question 5

Epidermis

Answer 5

outermost layer of the skin, and the thinnest; regenerates ever 4-6 weeks

Question 6

Subdivisons of the epidermis:

Answer 6

stratum corneum
stratum lucidum 
stratum granulosum
stratum spinosum
stratum germinativum (basal layer)

Question 7

Stratum Corneum:

Answer 7

made up of flattened dead cells

Question 8

The middle 3 layers provide a transition from:

Answer 8

stratum corneum to stratum germinativum (which also help in reduction of friciton and shear)

Question 9

Stratum Germinativum:

Answer 9

constantly produces new cells that are pushed up (protein keratin is synthesized here)

Question 10

Keratin:

Answer 10

gives the skin strength and flexibility and allows the skin to repair itself

Question 11

Melanin:

Answer 11

gives the skin its color and protects from UV light and Langerhans cells

Question 12

Langerhans cells:

Answer 12

involved in digestion of bacteria and the immune system’s response to foreign materials

Question 13

Dermis:

Answer 13

lying between the epidermis and the deeper subcutaneous layer

Question 14

The epidermal and dermal layers are joined together by the:

Answer 14

basal membrane

Question 15

Rete Ridges/Papillary Dermis:

Answer 15

provides the stick that anchors these layers of the skin together, preventing them from sliding back and forth

Question 16

Embedded in the dermis:

Answer 16

sebaceous glands
sweat glands
hair/nail follicles
nerves
lymphatics

Question 17

Subcutaneous layer:

Answer 17

layer of adipose tissue; in addition to attaching the dermis to the underlying muscles and bones delivers the blood supply to the dermis, provides insulation

Question 18

Open wound:

Answer 18

actual break in the skin’s surface

example: abrasion,. puncture/surgical wound

Question 19

Closed wound:

Answer 19

seen with bruising, and the skin is still intact

Question 20

Superficial wound:

Answer 20

involves only the epidermis

Question 21

Partial thickness wound:

Answer 21

involves the epidermis and the dermis but does not extend to the subcutaneous layer

Question 22

What do partial thinkness and superficial wounds have in common?

Answer 22

these wounds heal quickly and leave no scaring

Question 23

Full thickness wound:

Answer 23

extends through the dermis to the subcutaneous layer and may extend farther to the muscle, bone, or other underlying structures.

Question 24

How do full thickness wounds heal:

Answer 24

heal slowly and leave scarring; more likely to become chronic

Question 25

Burns:

Answer 25

tissue injuries caused by heat, electricity, chemical radiation, extreme cold, or friction

Question 26

Clean wound:

Answer 26

no infection and risk for developing infection is low

Question 27

Clean contaminated wound:

Answer 27

similar to a clean wound, but because the surgery involves organ systems that are likely bacteria, the risk for infection is greater

Question 28

Contaminated wounds:

Answer 28

result from a break in sterile technique during surgery; have a higher risk of infection

Question 29

Infected wounds:

Answer 29

shows clinical signs of infection including redness, warmth, and increased drainage

Question 30

Colonized wounds:

Answer 30

1 or more organisms are present on the surface of the wound; when a swab culture is obtained but there is not overt sign of infection in the tissue below the surface

Question 31

Acute wound:

Answer 31

wound that progresses through the phases of wound healing in a rapid, uncomplicated manner

Question 32

Approximated:

Answer 32

the edges of a wound can be brought together

Question 33

Primary Intention:

Answer 33

heal quickly and result in minimal scar formation

Question 34

Chronic wound:

Answer 34

fails to progress to healing in a timely manner

Question 35

Secondary Intention:

Answer 35

new tissue must fill in from the bottom and the sides of the wound until the wound bed is filled with new tissues

Question 36

Tertiary Intention:

Answer 36

a delay occurs between injury and closure

Question 37

Phases of wound healing:

Answer 37

inflammation proliferative maturation

Question 38

Inflammatory Phase:

Answer 38

beings with the body's initial response to wounding of the skin and last about 3 days (a the end of this phase, the wound bed is clean and ready to being the actual repair process)

Question 39

Proliferative Phase:

Answer 39

healing/repair of the defect, filling in the wound bed with granulation tissue, and resurfacing the wound with skin.

Question 40

Granulation tissue:

Answer 40

new tissues created to fill the wound

Question 41

Angiogenesis:

Answer 41

development of new blood vessels that are needed to support the new tissue, collagen synthesis, wound contraction, and epithelialization

Question 42

Fistula:

Answer 42

abnormal connections between two internal organs or between an internal organ through the skin, outside of the body q

Question 43

Pressure Injury:

Answer 43

localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combo with shear

Question 44

Capillary closing pressure/critical closing pressure:

Answer 44

minimum pressure required to collapse a capillary

Question 45

Low levels of pressure over long periods of time can be:

Answer 45

as damaging to the skin and underlying tissue as high levels of pressure over a short period of time

Question 46

Maceration:

Answer 46

excessive moisture causes softening of the skin

Question 47

Stage I pressure ulcer:

Answer 47

intact, nonblistered skin with nonblanchable erythema or persistent redness, in the ares that has been exposed to pressure.

Question 48

Stage II pressure ulcer:

Answer 48

partial thickness would that involves the epidermis and/or dermis but does not extend below the level of the dermis

Question 49

Maturation Phase:

Answer 49

(remodeling phase) can last up to a year; collagen continues to be deposited and remodeled and scar tissue is formed and strengthens

Question 50

Scar Tissue:

Answer 50

a vascular mass of collagen that give strength to the repaired wound (strength of the scar is never equal to that of unwounded tissues; it only reached about 80% of its previous tensile strength)

Question 51

Factors affecting wound healing:

Answer 51

``` oxygenation and tissue perfusion diabetes nutrition age infection ```

Question 52

Dehiscence:

Answer 52

partial or complete separation of the tissue layers during the healing process

Question 53

Evisceration:

Answer 53

total separation of the tissue layers allowing the protrusion of visceral organs through the insision

Question 54

Teach patient to splint the incision with a pillow or blanket or to use an abdominal binder while:

Answer 54

coughing, deep breathing, and movement

Question 55

Serous drainage:

Answer 55

clear, watery fluid

Question 56

Serosanguineous drainage:

Answer 56

pink to pale red and contains a mix of serous fluid, and red bloody fluid

Question 57

Sanguineous fluid:

Answer 57

indicated bleeding and is bright red

Question 58

Change a patient's position at least:

Answer 58

every 2 hours

Question 59

Debridement:

Answer 59

removal of necrotic tissue

Question 60

Hospital acquired pressure ulcers are:

Answer 60

NOT reimbursed

Question 61

Abnormal reactive hyperemia:

Answer 61

the redness in Stage I and is due to excessive vasodilation caused by pressure

Question 62

Purulent drianage:

Answer 62

thick and indicates infection; can be yellowish, greenish, or beige

Question 63

Hydrocolloids:

Answer 63

adhesive dressings that provide a moist wound environment and their absorbent capabilities prevent the wound bed and surround tissue from becoming to wet. (not recommended for wounds suspected of being infected)

Question 64

Stage III Pressure Ulcer:

Answer 64

full thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue

Question 65

Undermining:

Answer 65

area of tissue loss present under intact skin usually along the edges of the wound, forming a "lip" around the wound

Question 66

Tunnel or sinus tract:

Answer 66

narrower passage way extending outward from the edge of the wound

Question 67

Stage IV pressure ulcer:

Answer 67

deeper than stage III and involves exposure of muscle, bone, or connective tissue

Question 68

Osteomyelitis:

Answer 68

infection of the bone

Question 69

Unstageable pressure ulcer:

Answer 69

full thickness wound in which the amount of necrotic tissue in the wound bed makes it impossible to assess the depth of the wound or the involvement of underlying structures

Question 70

Suspected deep tissue injury:

Answer 70

area of intact skin that is purple or a blood filled blister

Question 71

Gels:

Answer 71

add moisture to a wound thus creating a most environment and allowing autolytic debridement and wound healing to occur. (don't absorb little wound drainage and thus are inappropriate for a highly exudative wound

Question 72

Foams:

Answer 72

pull fluid away from the wound bed yet maintain a most wound environment, used for wounds producing moderate to heavy amounts of exudate and should not be used for wounds with only a small amount of drainage (do not relieve pressure)`

Question 73

Transparent films:

Answer 73

stick to the periwound skin but not to the actual wound bed- not appropriate for wounds with more than a minimal amount of drainage. the films prevent bacteria and fluids from enter the wound but allow oxygen and water vapor to move through the dressing. they imitate that action of a blister by keeping the body's own wound fluid next to the wound bed, maintaining a moist environment

Question 74

Gauze:

Answer 74

isn't effective as a barrier against infection removal often results in pain and damage to the wound bed, fibers can be left, also has an inability to maintain a most wound environment required for healing for healing, gauze is preferable for allowing the wound to become dry useful in cover dressings, and for absorbing exudate from a healing draining wound

Question 75

Alignates:

Answer 75

useful in highly exudative wounds should be avoided in dry wounds, have the ability to stop bleeding