Skin integrity and wound healing

Question 1

The three layers of skin

Answer 1

Epidermis
Dermis
Subcutaneous fat

Question 2

Skin protects against ….

Answer 2

pathogens

Question 3

Dermis is relied on for

Answer 3

nutrition

Question 4

Wound type:

epidermis and partial loss of dermis

Answer 4

partial thickness wound

Question 5

Wound type:

All through dermis up to subcutaneous fat and possibly muscle and bone

Answer 5

Full thickness wound

Question 6

another name for flesh eating disease

Answer 6

necrotizing fasciitis

Question 7

Wound that heals in 6 months or less

Answer 7

acute

Question 8

Wound that takes more than 6 months to heal

Answer 8

Chronic

Question 9

Any break in skin is

Answer 9

an open wound

Question 10

Open traumatic wound like a compound fracture is

Answer 10

Contaminated wound

Question 11

wound caused by friction

Answer 11

abrasion

Question 12

wound caused by penetrating trauma

Answer 12

Puncture

Question 13

Deep, jagged cut in skin

Answer 13

laceration

Question 14

laceration may be kept open for __ days to make sure no infection occurs

Answer 14

3 days

Question 15

Another name for pressure ulcer

Answer 15

Decubitus

Question 16

wound caused by skin trapped between a boney prominence and a hard surface

Answer 16

Pressure ulcer

Question 17

Blood vessel collapse=

Answer 17

no blood flow

Question 18

No blood flow =

Answer 18

necrosis

Question 19

MDRPI

Answer 19

Medical device related pressure injury

Question 20

Pressure ulcers are

Answer 20

not billable because they are preventable

Question 21

Pressure Ulcer stage:

Blanchable, Redness fades in 1-2 hours

Answer 21

At risk

Question 22

Pressure ulcer stage:

Non blanchable, stays red over compressed area, Skin intact

Answer 22

Stage 1

Question 23

Pressure ulcer stage:

Skin break, superficial, like an abrasion, blister

Answer 23

Stage 2

Question 24

treatment for stage 1 pressure ulcer

Answer 24

Relieve pressure, reposition, report

Question 25

Treatment for stage 2 pressure ulcer

Answer 25

Saline dressing, moist environment

Question 26

Esbar

Answer 26

Black slough dead tissue rubbed off

Question 27

Pressure ulcer stage: Full thickness with damage or loss of subcutaneous tissue

Answer 27

Stage 3

Question 28

Treatment for stage 3 ulcer

Answer 28

Usually requires debridement, wet to dry dressings, surgical intervention

Question 29

Debriding agent- chemical

Answer 29

santyl and collagenase combined with saline to activate

Question 30

If an ulcer is completely yellow, it is considered

Answer 30

unstageable

Question 31

An unstageable ulcer needs _____ to determine stage

Answer 31

debriding

Question 32

Pressure Ulcer stage: Full thickness loss with destruction of muscle, bone or supporting structures (tendons, joint capsule)

Answer 32

Stage 4

Question 33

Treatment for Stage 4 Ulcer

Answer 33

Non adherent dressing. May need skin grafts, flaps

Question 34

Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure &/or shear.

Answer 34

Deep tissue injury

Question 35

Deep tissue injury on an arm is considered

Answer 35

a bruise

Question 36

Base of wound builds from inside out, taking up to a year to heal

Answer 36

Epithelization

Question 37

A process by which fibrous tissue rich with blood capillaries replaces blood clots formed at the site of a healing wound.

Answer 37

Tissue granulation

Question 38

Stable eschar on heels should

Answer 38

not be removed

Question 39

Scale used to determine risk for ulcer

Answer 39

Braden scale

Question 40

Sometimes stage 3 and 4 are less ____ than stage 1 and 2

Answer 40

less painful

Question 41

Rash level with the skin surface

Answer 41

Macular rash

Question 42

rash involving elevated, raised area

Answer 42

papular rash

Question 43

rash covering most of body

Answer 43

generalized rash

Question 44

Itching and redness

Answer 44

pruritus

Question 45

increased pressure with one anatomical compartment characterized by pain, numbness, decreased mobility that is caused by edema

Answer 45

Compartment syndrome

Question 46

Bring back to normal

Answer 46

hemostasis

Question 47

Last 3 days with vasodilation, red, pain, warm swelling

Answer 47

inflammation

Question 48

hemostasis Inflammation Proliferation maturation

Answer 48

partial thickness wound healing or full thickness healing

Question 49

Wounds with minimal tissue loss ex. clean surgical wounds Edges of the primary wound can be approximated by sutures, staples, or tape Healing by collagen synthesis occurs Granulation tissue is not visible

Answer 49

Primary intention

Question 50

Tissue loss, edges that do not easily approximate ex. burns, pressure ulcers, deep lacerations Healing involves inflammation, filling by granulation tissue & then epithelial cells Scar is usually large & definite

Answer 50

Secondary Intention

Question 51

Occurs when there is a delay between injury and wound closure. Usually due to wait for underlying infection or edema to resolve. Some granulation tissue forms.

Answer 51

Tertiary intention

Question 52

An abnormal tube- like passageway that forms between two organs or from one organ to the outside of the body

Answer 52

Fistula

Question 53

A total or partial disruption of wound edged. The patient feels a “giving away” sensation

Answer 53

Dehiscence

Question 54

Is the protrusion of viscera through the abdominal opening

Answer 54

Evisceration

Question 55

Wound terms: Watery, clear, light yellow

Answer 55

Serous

Question 56

Wound term: Bloody

Answer 56

Sanguineous

Question 57

Wound term: Pink, yellow drainage

Answer 57

Serosanguinous

Question 58

Wound term: Yellow, green, tan and foul smelling (infection)

Answer 58

Purulent

Question 59

DSD

Answer 59

Dry sterile dressing

Question 60

Dressing types needed are determined by

Answer 60

Doc order

Question 61

MARSI

Answer 61

Medical adhesive related skin injury

Question 62

Using negative pressure to speed tissue healing

Answer 62

Vacuum assisted closure

Question 63

Vacuum uses continuous pressure at

Answer 63

125

Question 64

High Air Loss-air blows through “sand like” silicon beads making the surface less than capillary pressure in the skin. Feels like a water bed when on & becomes a firm hard surface when off is capable of holding a patient in position Causes a high fluid loss from the patient

Answer 64

Alternating Air-Pressure Mattress

Question 65

Heating unit consistent of waterproof pad thru which water circulates-for inflammation muscle spasms etc.

Answer 65

Aquathermia Pads