Week 4 Skin Integrity and Wound Assessment

Question 1

Skin functions

Answer 1

• Protects
• Regulates
• Receives sensation

Question 2

Factors affecting skin integrity

Answer 2

Resistance to injury of skin and mucous membranes varies among people
- Age
- Amount of underlying tissues (thin)
- Conditions
- Some medications
- Impaired circulation
- Nutritional state

Question 3

Adequate ____ is necessary to maintain cell life

Answer 3

Circulation

Question 4

Skin gland secretions peak during

Answer 4

Adolescence and continues until about 50

Question 5

Age related skin changes

Answer 5

• Skin more easily injured
• Less capacity to insulate
• Sensation is reduced
• skin becomes drier
  -ealing time delayed
• Uneven pigment
• Loss of skin elasticity

Question 6

Loss of epidermis only

Answer 6

Superficial

Question 7

Involves the dermis and epidermis

Answer 7

Partial thickness

Question 8

Involves the epidermis, dermis, subcutaneous fat, muscle, and sometimes bone

Answer 8

Full thickness

Question 9

How many phases are there of wound healing?

Answer 9

3

Question 10

Inflammatory phase

Answer 10

Phase 1 (0-3 Days)

Question 11

Proliferative phase

Answer 11

Phase 2 (3-24 Days)

Question 12

Maturation phase

Answer 12

Phase 3 (24-365 Days)

Question 13

Contributing factors to impaired healing

Answer 13

• Unstable diabetes mellitus
• Venous or arterial disease
• Ageing
• Infection

Question 14

Maceration

Answer 14

pH of skin

Question 15

Oedema

Answer 15

Inadequate O2 and blood

Question 16

Necrosis

Answer 16

Dead tissue which must be removed

Question 17

Wound not progressing through stages of healing in a timely manner

Answer 17

Chronic wound

Question 18

Chronic wounds due to___ factors

Answer 18

Intrinsic and extrinsic

Question 19

Exudate

Answer 19

• Contains nutrients, energy and growth factors for metabolising cells
• Contains high quantities of WBCs
• Cleanses the wound
• Maintains a moist environment
• Promotes epithelisation

Question 20

Exudate
Clear, straw coloured

Answer 20

Serous (normal)

Question 21

Exudate
Clear, pink

Answer 21

Haemoserous (normal)

Question 22

Exudate
Red

Answer 22

Sanguinous (trauma to blood vessels)

Question 23

Exudate
Yellow, grey, green

Answer 23

Purulent (Infection)

Question 24

A technique which aims to prevent pathogenic microorganisms from being introduced to susceptible sites by hands, surfaces/equipment

Answer 24

Aseptic

Question 25

Preventing contamination of susceptible sites by hands, surfaces/equipment

Answer 25

Non-touch

Question 26

Identifying the risk of contamination and choosing the right field and technique

Answer 26

Technique

Question 27

Technically simple, short in duration (<20 min) involving relatively few and small key sites and parts

Answer 27

Standard ANTT

Question 28

Main general aseptic field and non-sterile gloves

Answer 28

Standard ANTT

Question 29

Technically complex surgery involving extended time periods with large open key sites or large or multiple key parts

Answer 29

Surgical ANTT

Question 30

Main critical aseptic field, sterile gloves and barrier precautions

Answer 30

Surgical ANTT

Question 31

Open wounds, including insertion and puncture sites

Answer 31

Key SITES

Question 32

Parts of procedure equipment coming into direct or indirect contact with other key parts, any liquid infusion or key sites

Answer 32

Key PARTS

Question 33

Clinical manifestations of wound infection

Answer 33

- Localised heat - Erythema - Fever - Odour -Increased exudate - Increased pain - Slow healing - Cellulitis

Question 34

Wound cleansing

Answer 34

- Normal saline used - Cleanses bacteria from wound - Assists debridement - Adhere to ANTT principles

Question 35

When should you swab a wound for testing?

Answer 35

After cleansing, but before antibiotics

Question 36

Used when Key parts/sites are large or numerous and can’t be easily protected by covers or caps or can’t be handled with a non-touch technique

Answer 36

Critical aseptic field

Question 37

The phases of wound healing occur in the following order:

Answer 37

Inflammatory, Proliferative, Maturation.

Question 38

Most superficial layer of the skin and provides the first barrier of protection from the invasion of substances into the body

Answer 38

Epidermis

Question 39

Connective tissue layer between the epidermis and subcutaneous tissue

Answer 39

Dermis

Question 40

Removal of infected and necrotic tissue

Answer 40

Debridement

Question 41

The partial or total rupturing of a sutured wound

Answer 41

Dehiscence

Question 42

Loss of the superficial layers of the skin

Answer 42

Excoriation

Question 43

Dead tissue in wound usually cream or yellow in colour

Answer 43

Slough

Question 44

Material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces

Answer 44

Exudate

Question 45

Young connective tissue with new capillaries formed in wound healing process

Answer 45

Granulation tissue

Question 46

A collection of blood in a tissue, an organ or a space due to a break in the wall of a blood vessel.

Answer 46

Haematoma

Question 47

Indicates freedom from infection or pathogenic material.

Answer 47

Asepsis

Question 48

Aims to prevent pathogenic organisms, in sufficient quantity to cause infection, from being introduced into susceptible body sites by the hands of staff, surfaces of equipment.

Answer 48

Aseptic technique

Question 49

Smaller parts of equipment that must be protected and kept sterile during an aseptic procedure

Answer 49

Micro critical aseptic field

Question 50

Simple aseptic field where there may be a small number of key parts and small key sites

Answer 50

General aseptic field