Skin Integrity & Wound Care

Question 1

tool used to predict pressure sore risk used in conjuction with nursing judgment…low score= high risk…15-18 low risk, 13-14 moderate risk, 10-12 high risk, <9 very high risk

Answer 1

Braden Scale

Question 2

removal of necrotic tissue

Answer 2

Debridement

Question 3

partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly (obese pt at high risk, most common in abdominal wounds post-surgery)…BE ALERT WHEN SEROSANGUINEOUS DRAINAGE INCREASES!

Answer 3

Dehiscence

Question 4

thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn; slough present in stage IV ulcers (may be allowed to naturally remove or may be surgically removed)

Answer 4

Eschar

Question 5

occurs when wound layers separate below the fascial layer and visceral organs protrude through the wound opening…medical emergency requiring placement of sterile towels soacked in sterile saline over the extruding tissues to reduce chances of bacterial invasion & drying before surgery

Answer 5

Evisceration

Question 6

surface damage caused by the skin rubbing against another surface that often results in an abrasion

Answer 6

Friction

Question 7

red, moist tissue consisting of blood vessels and connective tissue

Answer 7

Granulation Tissue

Question 8

softening of the skin caused by moisture

Answer 8

Maceration

Question 9

impaired skin integrity resulting from pressure

Answer 9

Pressure Ulcer

Question 10

force exerted against the skin while the skin remains stationary and the bony structures move

Answer 10

Shearing Force

Question 11

healing that occurs in a wound with little or no tissue loss such as a clean surgical incision; the skin edges approximate and risk for infection is minimal

Answer 11

Primary Intention

Question 12

healing that occurs in wounds involving loss of tissue such as a severe laceration or chronic wound; skin edges cannot come together because of the extensive tissue loss and healing occurs gradually

Answer 12

Secondary Intention

Question 13

healing that occurs when a wound is later brought together some type of closure material; occurs in wounds that are fairly deep and contain extensive draining & tissue debris; “delayed primary healing”

Answer 13

Tertiary Intention

Question 14

sensitive vascular layer of skin directly below the epidermis composed of collagenous and elastic fibrous connective tissues that give it it’s strength and elasticity

Answer 14

Dermis

Question 16

fluid, cells or other substances that have been slowly discharged from cells or blood vessels through small pores or breaks in cell membranes

Answer 16

Exudate

Question 17

clear, watery plasma drainage

Answer 17

Serous Drainage

Question 18

fresh bleeding drainage

Answer 18

Sanguinous Exudate

Question 19

pale, more watery, combination of plasma and red blood cells, blood-streaked drainage

Answer 19

Serosanguinous Exudate

Question 20

thick, yellow/green/brown drainage indicating presence of dead or living organisms and white blood cells

Answer 20

Purulent Exudate

Question 21

act of forming pus

Answer 21

Suppuration

Question 22

closing together of wound edges in which an injury has been caused on the skin by abrasion

Answer 22

Approximated Excoriation

Question 24

occurs when epithelial tissue grows from edges and covers over the granulation (new skin/scar)

Answer 24

Epithelialization

Question 25

abnormal passage from an internal organ to the body surface or between two internal organs

Answer 25

Fistula

Question 26

decreased blood supply to a body part, such as skin tissue, or to an organ, such as the heart

Answer 26

Ischemia

Question 27

the death of tissue in response to disease or injury

Answer 27

Necrosis

Question 28

discoloration of the ski nor bruise caused by leakage of blood into subcutaneous tissues as a result of trauma to underlying tissues

Answer 28

Ecchymosis

Question 29

present in Stage IV ulcers...a narrow canal underneath surface

Answer 29

Tunneling/Undermining

Question 30

abdominal binder used to support large incisions that are vulnerable to stress when the patient moves or coughs

Answer 30

Montgomery Straps

Question 31

the process of drying up

Answer 31

Desiccation

Question 32

pressure sore/ ulcer

Answer 32

Decubitus

Question 33

a soft tube placed in an operative site connected to a small, compressed, plastic bulb to drain blood & inflammatory fluid

Answer 33

Jackson-Pratt Drain

Question 34

a thin-walled rubber tubular drain made in various widths for use in surgery

Answer 34

Penrose Drain

Question 35

reaction phase of wound healing that begins within minutes of injury and lasts 3-6 days; characterized by vasoconstriction then dilation & slight fever (\<101)

Answer 35

Inflammatory Phase of Wound Healing

Question 36

phase of wound healing that starts on day 21 and can last long periods of time in which collagen scars gain strength, resume normal appearance becoming smaller, flatter, whiter; can take months-years to complete

Answer 36

Maturation/Remodeling Phase of Wound Healing

Question 37

phase of wound healing that starts around day 3 and lasts until day 21 in which macrophages are clear of debris and new blood vessels appear; granulation fills wound and then topped with epithelilization; pink, raised scar forms

Answer 37

Proliferative Phase of Wound Healing

Question 38

redness and edema are the first response, bringing WBC to the site (wound appears red & swollen), a scab forms when WBC dry; this response is limited and subsides in less than 24 hours

Answer 38

Inflammatory Response

Question 40

injury precipitates release of chemicals; complement and blood-clotting systems; activates inflammatory process

Answer 40

Stage 1 of Inflammatory Process

Question 41

stage characterized by erythema (increased blood flow to the area), redness, and increased warmth

Answer 41

Stage 2 of Inflammatory Process

Question 42

stage characterized by capillary permeability with leakage of large quantities of plasma into damaged tissues and non-pitting edema; infection walled-off

Answer 42

Stage 3 of Inflammatory Process

Question 43

stage in which damaged tissue is invaded by leukocytes that engulf bacteria and necrotic tissue; purulent exudate (pus) produced

Answer 43

Stage 4 of Inflammatory Process

Question 44

stage in which destroyed tissue cells are replaced by identical cells which promotes healing and formation of scar tissue; functional capacity of tissue may be reduced

Answer 44

Stage 5 of Inflammatory Process

Question 45

water-loving colloids applied to draining wound that forms gel to provide moisture for wound healing; has limited absorption; not adequate for large amts of exudate

Answer 45

Hydrocolloids

Question 46

used with primary dressing to prevent dehydration of wound base; can be used on infected wounds

Answer 46

Foam

Question 47

used for wounds with large amts of exudate; conforms to size/shape of base; must be irrigated to remove; not used in wounds with tunneling or sinus tracts

Answer 47

Absorption Dressing

Question 48

semi-permeable first dressings used to promote moist wound healing; water vapor passes through reducing periwound maceration; non-absorptive so drainage accumulates

Answer 48

Transparent Dressing

Question 49

soft, non-woven fibers made from seaweed, sodium & calcium acids that turns into non-adhesive gel when in contact with exudate; highly absorbent so will dry out wound bed; easy to irrigate out of wound; non-toxic; can control minor bleeding

Answer 49

Calcium Alginates

Question 50

dressing with cooling effect that enhances epithilization without reinjuring tissue and does not adhere to wound base; softens slough and necrosis; can be used on infected wounds; can macerate periwound skin

Answer 50

Hydrogels

Question 51

4x4's and roller gauze made of woven & non-woven fibers (cotton, rayon, polyester, combination); fine mesh gauze used in packing; coarse mesh used in debridement dressings; synthetic more absorbent than cotton; may be impregnated with wound products to promote healing

Answer 51

Gauze Dressings

Question 53

Factors that Affect Wound Healing

Answer 53

age, mobility, nutrition, hydration, diminished sensation, impaired circulation, medications, moisture on skin, fever, lifestyle

Question 54

vasodilation, reduced blood viscosity, reduced muscle tension, increased tissue metabolism, increased capillary permeability

Answer 54

Physiological Responses to Heat Therapy

Question 55

vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, decreased muscle tension

Answer 55

Physiological Response to Cold Therapy

Question 56

Conditions Treated with Heat Therapy

Answer 56

arthritis, joint pain, muscle strains, low back pain, menstrual cramping, hemorrhoidal, perianal, vaginal, local abscesses

Question 57

Conditions Treated with Cold Therapy

Answer 57

direct trauma, superficial laceration or puncture, minor burn, after injections, arthritis, joint trauma

Question 58

Conditions that Increase Risk for Injury from Heat/Cold Therapy

Answer 58

very young or old; open wounds; edema or scar formation; peripheral vascular disease; confusion or unconsciousness; spinal cord injury

Question 59

stage of ulcer characterized by nonblanchable erythema of intact skin where only the epidermis is involved; it is refeversible if the pressure is removed; TREATMENT: RELIEVE PRESSURE

Answer 59

Stage I Pressure Ulcer

Question 60

stage of ulcer characterized by partial-thickness skin loss involving epidermis and/or dermis; superficial skin tears; presents as abrasion, blister or shallow crater; may be swollen and painful; TREATMENT: MOIST HEALING ENVIRONMENT (SALINE OR OCCLUSIVE DRESSING)

Answer 60

Stage II Ulcer

Question 61

stage of ulcer characterized by full-thickness skin loss with damage or necrosis of subcutaneous tissue that may extend to but not through the underlying fascia; presents as deep crater with or without underminding; may have foul-smelling drainage; TREATMENT: DEBRIDE WITH WET-TO-DRY, SURGERY, ENZYMES

Answer 61

Stage III Ulcer

Question 62

stage of ulcer characterized by full-thickness skin loss with extensive destruction, tissue necrosis or damage to to muscle, bone or supporting structures with undermining possible present; TREATMENT: NON-ADHERENT DRESSINGS, SKIN GRAFTS

Answer 62

Stage IV Ulcer

Question 63

localized area of purple/maroon discoloration; intact skin or blood blister due to damage of underlying soft tissue from pressure/shear; painful, mushy, boggy, warm/cool in comparison to adjacent tissue

Answer 63

Deep Tissue Injury

Question 64

ulcer in which the base is covered in slough and/or eschar and therefore, cannot visually be graded or staged

Answer 64

Unstageable Ulcer

Question 66

Changes in Skin Associated with Aging

Answer 66

decreased tears/blink reflex, drying of oral mucosa, thinning of skin, decreased oil production, decreased body mass