46 - Skin integrity/Wound Care

Question 1

Blanching

Answer 1

skin turns lighter colour when pressured then reutrns to normal colour

Question 2

hyperemia

Answer 2

an excess of blood in the vessels supplying an organ or other part of the body.

Question 3

Pressure intensity

Answer 3

amount of pressure needed to close capillary, especially susceptibility if reduce sensation and can’t shift to offload pressure, tissue death may occur

Question 4

Tissue tolerance

Answer 4

ability of tissue to support pressure

Question 5

Pressure duration

Answer 5

assess amount of pressure and how long the pressure occurs

Question 6

Shear

Answer 6

force exerted parallel to skin. Skin adheres to surface and muscle/bone slide across the surface

Shear causes DEEP tissue damage, friction causes surface damage

Question 7

Tissue perfusion

Answer 7

amount of O2 reaching tissue cells (diabetes is a risk factor)

Question 8

Granulated tissue

Answer 8

red/moist shows that it’s healing

Question 9

Slough

Answer 9

stringly and yellow/white, attached to wound bed needs to be removed

Question 10

Eschar

Answer 10

brown/black necrotic tissue, must be removed

Question 11

Periwound

Answer 11

the whole area outside of the wound, is dry and clean.

raditionally limited to 4 cm outside the wound’s edge but can extend beyond this limit if outward damage to the skin is present

Question 12

Wound

Answer 12

A disruption of the integrity and function of tissues in the body

Question 13

Acute

Answer 13

caused by surgical incision. Heal in orderly manner

Question 14

Chronic

Answer 14

caused by vascular compromise and fail to heal properly

Question 15

Primary intention

Answer 15

wound that’s closed with sutures/staples, minimal scarring

Question 16

Secondary intention

Answer 16

wound edges don’t approximate (not pulled together), ex in pressure injury or when tissue is removed. Healed by filling in with scar tissue. Increased risk of injection since its open

Question 17

Tertiary intention

Answer 17

healing that occurs with wounds being open for several days then later approximated. Does when wound is contaminated/inflammed

Question 18

Skin tears

Answer 18

popular in elderly pop’s due to thin skin, dehydration, poor nutrition, prolonged corticosteroid use. Avoid using tape with this fragile of skin

Question 19

Venous and arterial ulcers

Answer 19

• result of poor circulation. Acount for 80% of leg wounds, have large amount of exudate. Due to pooling of blood in extremities. “wooden” like appearance. Dark/shiny. Treatment is compression therapy.
• Arterial ulcer looks like punched out skin

Question 20

Diabetic ulcer

Answer 20

results from poorly controlled diabetic. Neuropathic changes, debridment and appreciate dressing.

Question 21

Malignant or fungating wounds

Answer 21

painful have purulent dischange, and don’t heal.

Question 22

Abrasions

Answer 22

superficial with minimal bleeding, partial thickness wound

Question 23

Lacerations

Answer 23

jagged and unintentional. Bleed profusely

Question 24

Puncture

Answer 24

bleed in relation to depth or size

Question 25

Serous

Answer 25

clear watery plasma

Question 26

Sanguineous

Answer 26

bright red, indicated active bleeding

Question 27

Serosanguineous

Answer 27

pale red watery mixture of clear/red fluid

Question 28

Purulent

Answer 28

thick yellow/green/tan/brown, pus

Question 29

Hematoma

Answer 29

localized collection of blood underneath tissue

Question 30

Hemorrhage

Answer 30

bleeding from a wound site

Question 31

Dehiscence

Answer 31

when layers of skin/tissue begins to separate. People report feeling of something “giving way”

Question 32

Evisceration

Answer 32

Organs begin to protrude out. This is a medical emergency and needs immediate attention,

Question 33

Fistulas

Answer 33

abnormal passage between 2 organs or between organ and outside of body.

Question 34

Irrigation

Answer 34

use saline under pressure to cleanse wound

Question 35

Debridement

Answer 35

removal of non-viable tissue

Question 36

Stage I

Answer 36

Intact skin with nonblanchable redness

In stage I, the injury appears as a defined area of persistent redness in lightly pigmented skin and as a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. The skin is warmer or cooler there than in other areas, with a change in consistency and sensation.

Question 37

Stage II

Answer 37

Partial thickness loss of skin with exposed dermis

A stage II injury is characterized by partial-thickness skin loss involving the epidermis and possibly the dermis.

Question 38

Stage III

Answer 38

Full-thickness tissue loss with visible fat, rolled wound edges

In stage III, the injury appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia.

Question 39

Stage IV

Answer 39

Full-thickness tissue loss with exposed bone, muscle, or tendon

In stage IV, the injury is a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Question 40

Unstageable

Answer 40

Full-thickness tissue loss, in which the base of the ulcer is covered by slough or eschar in the wound bed

Question 41

Suspected deep tissue injury

Answer 41

Discoloured intact skin