Tissue Integrity

Question 1

The Epidermis is made of what?

Answer 1

Squamous epithelial cells

Question 2

What cells form the basal layer of the skin?

Answer 2

Keratinocytes

Question 3

What cells located in the epidermis make melanin?

Answer 3

Melanocytes

Question 4

What’s melanin?

Answer 4

A pigment that determines the color of the hair and skin

Question 5

What skin cells absorb radiant energy from the sun and protects the skin from the sun’s harmful UV rays?

Answer 5

Melanocytes

Question 6

What are Merkel cells?

Answer 6

Receptor cells that are specialized to detect light touch

Question 7

What cells package and ingest foreign antigens to be presented to lymphocytes?

Answer 7

Langerhans cells

Question 8

What do Langerhans cells play a role in?

Answer 8

Cutaneous immune system reactions

Question 9

Cutaneous means?

Answer 9

Relating to the skin

Question 10

What is the dermis layer of the skin composed of?

Answer 10

Composed primarily of connective tissues, but also has capillaries, blood vessels, and lymph vessels

Question 11

What does the dermis provide?

Answer 11

Strength and flexibility of the skin

Question 12

What layer of the skin assists in wound healing?

Answer 12

The dermis

Question 13

The subcutaneous layer (hypodermis) is composed of what?

Answer 13

Adipose tissue

Question 14

What does the subcutaneous layer does what?

Answer 14

Insulates the body, absorbs shock, and pads the internal organs + structures

Question 15

Maceration meaning?

Answer 15

Irritation of the epidermis caused by moisture

Question 16

Dermatitis meaning?

Answer 16

Red skin irritation that develops whenever the skin is exposed to irritants

Question 17

What’s a skin tear?

Answer 17

Loss of the top layer of skin caused by mechanical forces and tissue trauma

Question 18

What is cellulitis?

Answer 18

Infection of the upper layers of the skin

Question 19

Do collagen and elastic fibers increase or decrease as you age?

Answer 19

Decrease

Question 20

Erythema meaning

Answer 20

Redness of the skin due to dilation of blood vessels

Question 21

Blanchable erythema meaning?

Answer 21

Reddened skin that temporarily turns white or pale when light pressure is added. Skin reddens against once pressure is released

Question 22

Nonblanchable skin

Answer 22

Reddened skin that doesn’t turn pale or white when light pressure is applied

Question 23

What does nonblanchable skin indicate?

Answer 23

Structural damage has occurred to the small vessels carrying blood to the underlying skin and tissues

Question 24

Exudate

Answer 24

Fluid secreted by body during the inflammatory stage of healing. Made by plasma

Question 25

Moisture-associated skin damage (MASD) is a type of what?

Answer 25

Dermatitis

Question 26

How do chronic wounds develop?

Answer 26

They develop over time because of a disruption in the wound healing process or because of alterations in blood flow

Question 27

A chronic wound is what kind of wound?

Answer 27

A non-healing wound

Question 28

What does tunneling mean in skin terminology?

Answer 28

Narrow channel or passage extending in any direction from the base of the wound

Question 29

Shearing meaning?

Answer 29

Force parallel to the surface of the skin

Question 30

What is it called whenever the skin and muscles are pulled in opposite directions?

Answer 30

Shear forces

Question 31

What is hypoperfusion?

Answer 31

Low oxygen levels due to poor blood circulation

Question 32

What scale is used to check someone’s risk for alterations in tissue integrity?

Answer 32

Braden scale

Question 33

Undermining meaning?

Answer 33

An open area extending under skin along the edge of a wound

Question 34

What does benchmarking mean?

Answer 34

Comparing results and outcomes to other sources of similarly retrieved data

Question 35

How many stages of pressure injury are there?

Answer 35

4

Question 36

What is the first stage of pressure injury?

Answer 36

Nonblanchable erythema

Question 37

What is the second stage of pressure injury?

Answer 37

Partial-thickness skin loss

Question 38

What is the third stage of pressure injury?

Answer 38

Full-thickness skin loss

Question 39

What is the fourth stage of pressure injury?

Answer 39

Full-thickness skin and tissue loss

Question 40

What is a unstageable pressure injury?

Answer 40

Obscured full-thickness skin and tissue loss injury

Question 41

Slough definition?

Answer 41

Yellow, stringy nonviable tissue found in the base of the wound

Question 42

Eschar definition?

Answer 42

Hard nonviable black/brown tissue found in the wound bed

Question 43

Deep tissue pressure injury (DTPI) meaning?

Answer 43

Persistent nonblanchable pressure injury that can appear as a maroon, deep red, or purple color

Question 44

What is a mucosal membrane pressure injury caused by?

Answer 44

The insertion or placement of a foreign device

Question 45

Debridement meaning?

Answer 45

Surgically removing dead tissue or other debris that can cause infection

Question 46

What is negative pressure injury therapy used to assist?

Answer 46

The healing and closing of large wounds by reducing edema around the wound and increasing granulation tissue formation

Question 47

Hematoma meaning?

Answer 47

Accumulation of blood in the body (blood pooling in tissues)

Question 48

Sedona meaning?

Answer 48

Accumulation of serous fluid

Question 49

What’s a Penrose drain?

Answer 49

A flat, pliable passive drain that uses gravity to drain accumulated fluids

Question 50

What’s a Portable Wound Bulb Suction Device?

Answer 50

An active, closed system drain that uses negative suction to drain fluid from the wound

Question 51

What’s Large Bottle Drainage?

Answer 51

If a large amount of fluid is expected, a higher-pressure, large bottle is used

Question 52

What’s a circular portable wound suction device?

Answer 52

A special type of wound drainage system that is designed to continuously suction drainage from a wound by providing a low vacuum pressure

Question 53

Vasoconstriction meaning?

Answer 53

Narrowing of blood vessels due to acute blood loss, pain, and/or low body temp

Question 54

How many types of wound healing are there?

Answer 54

3

Question 55

When does primary healing occur?

Answer 55

Occurs in clean lacerations and surgical incisions closed with skin adhesives or sutures

Question 56

What type of wound healing is fastest?

Answer 56

Primary healing

Question 57

When does secondary healing occur?

Answer 57

When the wound is left open to heal and granulation tissue forms from the bottom up in the wound bed

Question 58

When is delayed primary closure?

Answer 58

When the wound is left open for 5 to 10 days before it’s closed with sutures

Question 59

When should delayed primary closure be used and why?

Answer 59

To decrease the risk the risk of infection. Used when the site isn’t considered clean at the time the injury occurred

Question 60

What are some of the main essential nutrients for wound healing and tissue strengthening?

Answer 60

Protein, omega-3 and omega-6 fatty acids, and vitamins A and C

Question 61

If a wound infection is suspected, what do you do to figure out if it is or not?

Answer 61

You do a wound culture collection

Question 62

What kind of solution is used to rinse a wound when doing a wound culture inspection?

Answer 62

0.9% sodium solution

Question 63

Why is 0.9% sodium chloride used when collecting a wound culture?

Answer 63

To prevent normal skin micro-organisms from contaminating the culture

Question 64

Dehiscence meaning?

Answer 64

Complete/partial separation of the suture line and underlying tissues. Occurs when a wound fails to heal properly

Question 65

Evisceration meaning?

Answer 65

Protrusion of internal organs through a surgical wound which has dehisced or opened

Question 66

Does a client with a Braden scale score of 23 have a higher risk of a tissue integrity issue than a client with a score of 9?

Answer 66

The higher the score, the less at risk you are for running into a tissue integrity issue

Question 67

How long does it typically take before you can remove staples?

Answer 67

A week or two

Question 68

What kind of wound dressing needs a secondary reinforcement?

Answer 68

An alginate dressing

Question 69

What kind of wound dressing can be used to combat wounds with necrotized tissues and eschars?

Answer 69

Hydrogel

Question 70

High-Fowler’s position has a downside. What’s the downside?

Answer 70

It increases the risk for shearing and alterations in skin integrity

Question 71

Is an increased blood glucose level a sign of sepsis?

Answer 71

Yes

Question 72

What kind of wound dressing is best used for covering superficial wounds that have minimal exudate?

Answer 72

A transparent film