Skin, Integrity, Wound Care

Question 1

Intact skin with non-blanchable redness
“at risk” people
Discoloration of skin, warmth, edema, hardness, or p!

Answer 1

Stage 1 ulcer

Question 2

i. surgical complication in which a wound rupture along a surgical incision

Answer 2

Dehiscence

Question 3

Hydrogel, what stage to use?

Answer 3

2, 4

Question 4

Full-thickness tissue loss with visible fat
Slough may be present
Bone/tendon is not directly palpable

Answer 4

Stage 3 ulcer

Question 5

Hydrocolloid, what stage to use?

Answer 5

1, 2, 3

Question 6

i. Not closed—fills with scar tissue
ii. Pressure ulcer, burns
iii. Longer healing time—more chance for infection

Answer 6

secondary intention

Question 7

Combine physically distinct components into a single product to provide multiple functions such as a bacterial barrier

Answer 7

Composite

Question 8

Intervention of wound care 5 things

Answer 8

a. Post and implement a turning schedule.
b. Obtain and place over the patient’s mattress a low-air-loss overlay.
c. Clean wound and periwound skin; dry periwound skin.
d. Apply a hydrocolloid dressing to the wound
e. Determine in collaboration with dietitian an appropriate diet.

Question 9

Partial-thickness skin loss involving epidermis, dermis or both
Shallow, open ulcer with red-pink would bed WITHOUT slough
Could be open/ruptured serum-filled or serosanguineous-filled blister

Answer 9

Stage 2 ulcer

Question 10

i. When surgical incision opens & the abdominal organs then protrude or come out of the incision
ii. EMERGENCY

Answer 10

Evisceration

Question 11

bright red; indicates active bleeding

Deep wounds

Answer 11

Sanguineous

Question 12

Factors influencing heat and cold tolerance (5)

Answer 12

1. Exposure time
2. Exposed skin
3. Temperature
4. Age
5. Perception of sensory stimuli

Question 13

Complications of wound healing (5)

Answer 13

Hemorrhage
Infection (2nd most common)
Dehiscence
Evisceration
Cultures

Question 14

First aid for Wounds

Answer 14

Hemostasis (control bleeding)
Bandage
Cleaning
Protection
Dressing

Question 15

Full-thickness tissue loss with exposed bone, muscle, or tendon

Answer 15

Stage 4 ulcer

Question 16

Purposes of dressings (6)

Answer 16

1. Protects from microorganisms
2. Aids in hemostasis
3. Promotes healing by absorbing drainage or debriding a wound
4. Supports wound site
5. Promotes thermal insulation
6. Provides a moist environment

Question 17

Two surfaces moving against each other
Happens on skin
“Sheet burn”

Answer 17

Friction

Question 18

Appropriate support surface for stage 1 or 2 ulcer

Answer 18

foam
avoid HOB elevation
limit sitting to 3x per day of 60 min or less

Question 19

Basic Skin cleaning (3)

Answer 19

1. Clean from least contaminated to the surrounding skin
2. Use gentle friction
3. When irrigating, allow the solution to flow from the least to most contaminated area (circular rotations)

Question 20

Risk factors for pressure ulcer development (6 things)

Answer 20

Impaired sensory perception
impaired mobility
Alteration in LOC
Shear
Friction
Moisture

Question 21

Effects of cold application

Answer 21

Vasoconstriction
Local anesthesia
Reduced cell metabolism & muscle tension
Increased BV

Question 22

REEDA

Answer 22

Redness
Edema
Ecchymosis
Discharge
Approximation (are edges closed)

Question 23

Wound irrigation, what is done?

Answer 23

a. Sterile technique
b. 35 mL syringe with 19-gauge soft Angiocatheter
c. Delivers safe pressure—doesn’t damage good healing tissue
d. Hold syringe 2.5 cm (1 in) about upper end of wound

Question 24

Factors influencing pressure ulcer formation and wound healing (5)

Answer 24

Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact of wounds

Question 25

Happens beneath the skin | Sliding movement of skin while the underlying muscle & bone are stationary

Answer 25

Shear

Question 26

Stage III ulcer treatment

Answer 26

Clean with: Prescribed dressing Surgical intervention Proteolytic enzymes Nutritional supplements Analgesic Antimicrobials (topical or systemic)

Question 27

Keeps wound slightly moist, releasing water

Answer 27

hydrogel

Question 28

i. Edges are approximated | ii. A surgical wound, that is closed (approximated)

Answer 28

primary intention

Question 29

3 pressure related factors

Answer 29

1. Pressure Intensity 2. Tissue tolerance 3. Pressure duration

Question 30

pale, pink, watery; mixture of clear & red fluid | Most often seen

Answer 30

Serosanguineous

Question 31

thick, yellow, green, tan, or brown

Answer 31

Purulent

Question 32

Stage IV ulcer treatment

Answer 32

non adherent dressing change ever 12 hrs

Question 33

Stage II ulcer treatment (4 things)

Answer 33

Maintain most healing environment Natural healing while preventing scar tissue Provide nutritional supplements Analgesics

Question 34

Black, brown, tan or necrotic tissue

Answer 34

eschar

Question 35

Clear, watery plasma

Answer 35

Serous drainage

Question 36

Appropriate support surface for stage 3, 4, unstageable ulcer

Answer 36

``` Avoid prolonged HOB elevation low-air loss alternating pressure air fluidized surface consider a wheelchair ```

Question 37

Gauze, what stage to use?

Answer 37

3, 4 & unstageable

Question 38

Transparent film, what stage to use?

Answer 38

1

Question 39

Usually absorbent, waterproof, adheres to surrounding skin

Answer 39

Hydrocolloid

Question 40

Effects of heat application Vaso- Reduced Increased

Answer 40

Vasodilation Reduced BV, muscle tension Increased tissue metabolism & capillary permeability

Question 41

Pressure Intensity

Answer 41

Tissue ischemia | blanching

Question 42

COCA

Answer 42

1. Color 2. Odor 3. Consistency 4. Amount

Question 43

Acute care--wound management (5)

Answer 43

1. Debridement: the removal of damaged tissue or foreign objects from a wound 2. Education 3. Nutritional status 4. Protein status 5. Hemoglobin: oxygen needed for wound healing