Skin & Wound Care - Unit 6

Question 1

What are some skin functions?

Answer 1

Protection, thermoregulation, sensation, metabolism and communication.

Question 2

What are some factors altering skin?

Answer 2

Age, sun, hydration, soaps, nutritions, medications, mechanical damage, chemical factors, infectious factors, allergic factors, misc factors.

Question 3

What is induration?

Answer 3

Hardened tissue.

Question 4

What are some parts of an infection?

Answer 4

Erythema, edema, induration, purulent drainage, crepitis, lack of healing.

Question 5

What are some parts of inflammation?

Answer 5

Erythema, edema, pain, heat and clear drainage.

Question 6

What is undermining?

Answer 6

Fibrous tissue is cut - decreases tensions in the wound, frees up edges, but might cause a problem if a nerve of blood vessel is cut.

Question 7

What is a partial thickness wound?

Answer 7

Shallow, painful epidermal loss and maybe has partial dermal loss.

Question 8

Full-thickness wound - what is it?

Answer 8

Loss of epidermal and dermal layers, and may extend to subcutaneous or fascia, muscle, or bone.

Question 9

What are some factors impacting wound healing?

Answer 9

Tissue perfusion, nutritional status, infection, immunosuppression, aging, etc.

Question 10

What are some classifications of wounds?

Answer 10

Pressure ulcer, diabetic ulcer, arterial ulcer, venous status ulcer, surgical wound and traumatic wound.

Question 11

What is a primary surgical wound?

Answer 11

Edges are very tight - minimum tissue loss.

Question 12

What is a secondary surgical wound?

Answer 12

Edges not well approximated. Could be from trauma or a burn.

Question 13

What is a tertiary (delayed secondary) wound?

Answer 13

Wound is left open until secondary can begin.

Question 14

Scar Tissue - never more than __ percent the strength it was.

Answer 14

80%

Question 15

Wounds are measured in __ x __ x ___.

Answer 15

LxWxD

Question 16

What is wound tunnelling?

Answer 16

It’s when the wound goes down, but off to the side. So don’t just stick a swap straight down - feel around!

Question 17

What are some foreign objects in a wound?

Answer 17

Sutures, staples, drains, mesh and packing.

Question 18

What are some structures in a wound?

Answer 18

Bone, tendon, vein/artery, muscle, etc.

Question 19

If a bone or tendon is exposed…..the wound can still heal on its own. T/F?

Answer 19

False - it will need other help!

Question 20

What is slough/necrotic tissue?

Answer 20

Moist, yellowish, devitalized.

Question 21

What is eschar tissue?

Answer 21

Dry, dead and thick.

Question 22

What is granulation tissue?

Answer 22

Beefy red to pink.

Question 23

Epithelialization - tissue type?

Answer 23

Regrowth of skin over wound.

Question 24

What is serous fluid?

Answer 24

Clear/thin/watery.

Question 25

Serosanguineous - what is it?

Answer 25

Clear with some blood.

Question 26

What is sanguineous fluid?

Answer 26

Bloody!

Question 27

What is purulent fluid?

Answer 27

Puss filled fluid.

Question 28

Periwound - maceration?

Answer 28

Redness/shrinking.

Question 29

Periwound - Callous?

Answer 29

Hardening/thickening of the outer layer.

Question 30

Periwound - Erythema?

Answer 30

Redness.

Question 31

Periwound - Yeast?

Answer 31

Fungus.

Question 32

Periwound - Intact?

Answer 32

Skin is there.

Question 33

Periwound - Crepitus?

Answer 33

Air/crackling around the wound.

Question 34

Pressure ulcer - what is shear?

Answer 34

Caused by interplay of gravity and friction.

Question 35

Pressure ulcer - what is friction?

Answer 35

Dermis and epidermis are abraided - like a sunburn!

Question 36

What can cause a pressure ulcer?

Answer 36

Immobility, sensory deficits, nutrition, circulation/oxygenation, moisture, age, diseases, meds, friction, shear, surgery, etc.

Question 37

Shear - skin sticks to a surface. T/F?

Answer 37

True!

Question 38

Dry skin is 2.5x more likely to ulcerate than healthy skin. T/F?

Answer 38

True!

Question 39

Skin with too much moisture is 5x more likely to ulcerate than dry skin. T/F?

Answer 39

True!

Question 40

Pressure Ulcer - Stage 1- Info

Answer 40

An alteration in intact skin with a change in one of the following - skin temp, consistancy, sensation. redness appears.

Question 41

Pressure ulcer - Stage 2 - Info?

Answer 41

Partial thickness skin loss involving epidermis and/or dermis. Superficial!

Question 42

Stage 3 Pressure Ulcer - Info?

Answer 42

Full thickness loss involving change or necrosis of subcutaneous tissues! Extends to, but not through, the fascia.

Question 43

Stage 4 Pressure Ulcer - info?

Answer 43

Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures.

Question 44

Only pressure ulcers are staged. And never backstage! T/F?

Answer 44

True!

Question 45

What are some goals of topical therapy?

Answer 45

Provide moist wound environment, either add/remove moisture and protect!

Question 46

What is hydrocolloid?

Answer 46

Contains hydroactive absorbative particle - creates a gel! Impermeable to urine, stool and bacteria.

Question 47

What are alginates?

Answer 47

Absorbative, gels in wound bed, biodegradable, but DO NOT USE on dry wounds.

Question 48

Semipermiable polyurethane foam?

Answer 48

Can be adhesive or not, absorbs excessive exudate and is semipermeable.

Question 49

Gel Dressings - ?

Answer 49

can me amorphus, sheet or impregnated gauze. These are soothing but can macerate wound edges if too wet.

Question 50

Silver - ?

Answer 50

Comes in all modes, has a long wear time and is antimicrobial.

Question 51

Wound Vac - what is it?

Answer 51

Provides suction! We change is every 48-72 hours - it sucks the shit out of the wound!