Tissue Integrity 2

Question 1

intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by

Answer 1

primary intention

Question 2

Have edges that are not well approximated

large open wounds, such as burns or major trauma which require more tissue replacement and are often contaminated, commonly heal by

Answer 2

secondary intention

Question 3

wounds healed by _________ or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, then are closed

Answer 3

tertiary intention

Question 4

is defined as a localized area of intact skin

Answer 4

stage 1 pressure injury

Question 5

injury involves partial thickness loss of dermis and presents as a shallow, open ulcer or a ruptured intact serum filled blister

Answer 5

stage 2 pressure injury partial thickness

Question 6

subcutaneous fat may be visible and epibole (rolled up wound edges) may occur, but bone, tendon, or muscle is exposed

Answer 6

stage 3 full thickness skin loss

Question 7

involve full thickness tissue loss with exposed or palpable bone, cartilage, bone, ligament, tendon, fascia or muscle.

Answer 7

stage 4 pressure injury full thickness and tissue loss

Question 8

full thickness and tissue loss in which the extent of tissue damage within an ulcer cannot be confirmed because it is obscured by slough or eschar

Answer 8

unstageable pressure injury

Question 9

the ability of body to regenerate and or repair to maintain normal physiological processes

Answer 9

tissue integrity

Question 10

according to the concept diagram for tissue integrity, which of the following are considered negative outcomes ?

Answer 10

pain
infection
decubiti
altered self image
loss of fluid
loss of electrolytes

Question 11

according to the concept diagram for tissue integrity, which of the following is considered interrelated concepts ?

Answer 11

immunity
sensory perceptions
mobility
perfusion
elimination
nutrition
thermoregulation
fluid and electrolyte imbalance

Question 12

according to the concept diagram for tissue integrity, which of the following is considered antecedents

Answer 12

good nutrition
adequate perfusion
lack of external trauma
limited pressure on site

Question 13

according to the concept diagram for tissue integrity, which of the following is considered attributes

Answer 13

integument structurally intact and functioning

normal healing process

Question 14

consequences of impaired tissue integrity can lead to

Answer 14

infection
impaired thermoregulation
impaired elimination
fluid and electrolyte imbalance
pain
safety risks
probelms with body image

Question 15

impaired tissue integrity can potentially occur in all individuals, populations at greatest risk are:

Answer 15

infants
children
older adults

Question 16

health conditions:
poor peripheral perfusion
malnutrition or obesity
dehydration or edema
impaired mobility
immunosuppression

exposure to irritants:
radiation, temperature extremes, chemical or mechanical trauma, medical treatments

tissue trauma:
friction, shearing moisture, pressure

Answer 16

individual risk factors to tissue integrity

Question 17

skin hygiene
adequate nutrition
avoidance of excessive sun exposure
burn safety precautions
dermal ulcer prevention

Answer 17

primary prevention tissue integrity

Question 18

ABCDE screening for malignant melanoma

Answer 18

secondary prevention: screening

tissue integrity

Question 19

antibiotics
steroids
emollients
chemotherapy agents

Answer 19

collaborative interventions

pharmacotherapy for tissue integrity

Question 20

phototherapy
surgical interventions
wound care
nutritional support

protien, vitamin A, and vitamin C are critical

Answer 20

collaborative interventions for tissue integrity

Question 21

SPF 30+, apply 15 minutes before sun, reapply every 2 hours

Answer 21

Sunscreen education