Tissue integrity

Question 1

epiderms contain what types of special cells

Answer 1

keratinocytes
melanocytes
merkel cells - light touch
langerhans cells

Question 2

what’s a part of the dermis

Answer 2

CT (collagen and elastic fibers) with capillaries, blood vessels, lymph vessels

Question 3

what’s subcutaneous tissue have and do

Answer 3

have blood vessels and nerves -> thermoregulation, sensation
protec, insulate

Question 4

maceration

Answer 4

irritation of the epidermis caused by moisture

Question 5

dermatitis

Answer 5

red skin irritation that develops when skin is exposed to feces, urine, stoma effluent, and wound secretions

Question 6

skin tears caused by what

Answer 6

loss of top layer of the skin from mechanical forces

Question 7

most common injuries associated with skin frailty

Answer 7

skin tears
pressure injuries
infections (cellulitis)

Question 8

cellulitis

Answer 8

infection of the superficial layers of the skin

Question 9

decreased skin properties in the elderly

Answer 9

less elastic
less subq tissue
less blood supply
less hydrated

Question 10

changes in skin properties in pts with decreased mobility

Answer 10

changes in thermoregulation
loss of collagen
muscle atrophy
impaired sensation
decreased blood flow
incontinence

Question 11

changes in skin properties in pts that are obese

Answer 11

decreased moisture
maceration
increased temperature
decreased blood and lymph flow

Question 12

radiation in cancer pts can change skin how

Answer 12

inflammation
decreased blood supply
skin surface damage

Question 13

erythema

Answer 13

bony prominences; redness of skin from dilation of blood vessels
blanchable or not

Question 14

blanchable vs. nonblanchable erythema

Answer 14

blanchable: temporarily becomes white when pressure is applied
nonblanchable: structural damage in the small vessels supplying blood to the underlying tissues

Question 15

lacerations

Answer 15

tears in the skin; typically from blunt or sharp objects and have an irregular or jagged shape
simple or complicated classification

Question 16

what type of wounds are considered for surgical ones

Answer 16

intentional acute wounds

Question 17

surgical wounds are classified into what based on cleaniness

Answer 17

clean: closed at completion
clean-contaminated: closed at completion
contaminated: left open with long term wound management

Question 18

surgical wound healing time and characteristics

Answer 18

red: 1-4 days
bright pink: 5-14 days
pale pink: 15 days - 1 yr

Question 19

exudate

Answer 19

fluid consisting of plasma that is secreted by the body during the inflammatory phase of healing; resolve by day 5 post surgery

Question 20

moisture associated skin damage (MASD)

Answer 20

form of dermatitis; from sweat, increased local skin temp, abnormal skin pH, deep skin folds

Question 21

cause of chronic wounds

Answer 21

develop over time from disruption of acute wound healing;
conditions that cause alterations to blood flow

Question 22

3 types of chronic lower extremity wounds

Answer 22

venous, arterial, neuropathic disease wounds;
predispose pts to develop pressure injuries

Question 23

serous exudate

Answer 23

thin, watery’ straw colored

Question 24

serosanguineous exudate

Answer 24

thin, watery with blood

Question 25

sanguineous exudate

Answer 25

bloody

Question 26

purulent exudate

Answer 26

green or yellow

Question 27

shearing

Answer 27

forces exerted parallel to the surface of the skin and pulled in opposite directions; sitting or lying on an incline (high fowler)

Question 28

what risk factors contribute to pressure injury development

Answer 28

immobility malnutrition reduced perfusion altered sensation decreased LOC

Question 29

friction

Answer 29

not direct cause to pressure injuries but increases their risk when force created from rubbing

Question 30

purpose of braden scale

Answer 30

rates pt risk for alterations in tissue integrity

Question 31

6 categories of braden scale

Answer 31

sensory perception moisture activity mobility nutrition friction & tear

Question 32

interpretation of Braden scale

Answer 32

each category is 0 - 4 adds up <18 is risk

Question 33

how should a nurse stage pressure injuries

Answer 33

nonblanchable erythema depth and amount of skin and tissue loss condition, presence of dead tissue tunneling undermining

Question 34

undermining

Answer 34

open area extending under skin along the edge of the wound

Question 35

benchmarking

Answer 35

comparing results and outcomes to toehr sources of similar data; rate pressure injuries stage 1 - 4

Question 36

stage 1 pressure injury

Answer 36

non-blanchable erythema

Question 37

stage 2 pressure injury

Answer 37

partial thickness skin loss pink or red tissue in wound bed

Question 38

stage 3 pressure injury

Answer 38

full thickness skin loss visible adipose tissue, granulation tissue: new skin tissue forming possible death tissue, edge rolled undermining/tunneling may be present

Question 39

granulation tissue

Answer 39

new skin tissue that forms on the surface of the wound

Question 40

stage 4 pressure injury

Answer 40

full thickness skin and tissue loss fascia, muscles, tendons, ligaments, cartilage, and or bone visible possible dead tissue, tunneling, edges rolled

Question 41

slough

Answer 41

yellow, stringy nonviable tissue found in the base of the wound; unstageable pressure injury

Question 42

eschar

Answer 42

hard nonviable black/brown tissue; removal shows stage 3 or 4 pressure injury

Question 43

deep tissue pressure injury (DTPI)

Answer 43

localized, non-blanchable, deep red, marron, or purple discoloration; cause of intense and or persistent pressure and shearing force

Question 44

mucosal membrane injury caused by what

Answer 44

insertion or placement of a foreign device such as endotracheal tubes, oxygen tubing, feeding tubes, drainage tubes

Question 45

correct position of bed to minimize risk of pressure injuries

Answer 45

less than 30 degrees to decrease risk of sliding down

Question 46

wound healing and tissue strengthening nutrients

Answer 46

protein omega3 & 6 fatty acids vitamins A and C minerals (Zn)

Question 47

why do steroids prevent wound healing

Answer 47

prevent formation of collagen and fibroblasts required for wound healing

Question 48

compare primary, secondary, and tertiary wound healing

Answer 48

primary: sutured secondary: left open tertiary: left open and then sutured

Question 49

list the 3 stages of wound healing

Answer 49

hemostatic/inflammatory phase proliferative phase remodeling phase

Question 50

most common cause of surgical site infections and prevention

Answer 50

Staph.aureus chlorhexidine prevent

Question 51

rinse wound culture with what before collecting sample

Answer 51

Na Cl cleaning before getting sample

Question 52

dehiscence

Answer 52

complete or partial separation of the suture line and underlying tissues; wound fails to heal properly due to poor surgical technique, infection, or foreign particles in wound

Question 53

signs of dehiscence

Answer 53

occurs 7-10 days after surgery; serosanguineous discharge

Question 54

evisceration

Answer 54

wound and all layers of tissue under the wound separate resulting in protrusion of intraabdominal organs through the suture line; sterile saline soaked dressing to cover

Question 55

hemorrhage

Answer 55

bleeding that is internal or external

Question 56

hematoma

Answer 56

accumulation of blood when clotting mechanisms fail could lead to wound ischemia; leading to necrosis

Question 57

higher risk pts for getting hematoma

Answer 57

anticoagulant medications obese pts

Question 58

hydrocolloid dressings

Answer 58

used in pressure injuries keep moisture, absorb exudate, protect,

Question 59

what is the PUSH tool

Answer 59

pressure ulcer scale for healing includes: LxW (in cm^2), exudate amount, and tissue type