skin integrity & wound care

Question 1

all/portion of dermis intact

Answer 1

partial thickness wound

Question 2

entire dermis, sweat glands, hair follicles involved

Answer 2

full thickness wound

Question 3

full thickness loss where depth cannot be determined

Answer 3

unstageable wound

Question 4

edges well approximated (sewn/sutured together); minimal tissue loss; ex: surgical procedure wounds

Answer 4

primary intention

Question 5

edges not approximated; open wounds from burns/trauma, likely involving contamination; take longer time to heal; scar tissue most likely present

Answer 5

secondary intention

Question 6

delayed primary closure; wounds left open for days to allow for edema/infection to resolve or fluid to drain first before closing wound

Answer 6

tertiary intention

Question 7

process of “drying up” of a wound

Answer 7

dessication

Question 8

partial/total separation wound formed from trauma, contaminated wound, wound involving intestine that’s at risk of being contaminated by fecal matter

Answer 8

dehiscence

Question 9

wound separates completely with viscera protruding through incision/wound; greater risk if obese, malnourished, smokers, using anticoagulants, infected, strain to site

Answer 9

evisceration

Question 10

fistula

Answer 10

abnormal passage from an organ to outside of body or from one organ/vessel to another; result of an infection

Question 11

risks for pressure injuries

Answer 11

immobility, nutrition/hydration status, mental status, age

Question 12

most common places for pressure injury to occur

Answer 12

sacrum, coccyx, heels

Question 13

shear

Answer 13

one layer tissue slides over another layer

Question 14

friction

Answer 14

two surfaces rub against eachother

Question 15

intact skin with nonblanchable redness of localized area

Answer 15

stage I

Question 16

partial thickness wound with loss of dermis; open ulcer with pink wound bed

Answer 16

stage II

Question 17

full thickness tissue loss; SQ tissue may be visible, not bone or muscle; undermining/tunneling may be present

Answer 17

stage III

Question 18

full thickness tissue loss with exposed bone, tendon, or muscle. usually involved undermining/tunneling

Answer 18

stage IV

Question 19

full thickness tissue loss with base of ulcer covered in slough/eschar

Answer 19

unstageable

Question 20

clear portion of blood; clear & watery

Answer 20

serous

Question 21

bright red blood, lots of RBCs in drainage, indicating fresh bleeding

Answer 21

sanguineous

Question 22

mixture or serum & RBCs; light pink to blood tinged

Answer 22

serosanguinous

Question 23

infection present; made up of WBCs; thick, often foul smelling; color can be yellow/green, depends on bacteria

Answer 23

purulent

Question 24

example of open system drain

Answer 24

penrose

Question 25

example of closed system drain

Answer 25

jackson-pratt; hemovac

Question 26

right after injury, blood clotting begins

Answer 26

hemostasis phase

Question 27

WBCs move to wound; characterized by pain, heat, redness, swelling at site; can have low grade fever, increased WBC, fatigue

Answer 27

inflammatory phase

Question 28

regenerative phase lasting weeks to months; new tissue fills wound space

Answer 28

proliferation phase

Question 29

collagen remodeled, scar may form

Answer 29

maturation phase