Ch 32: Skin Integrity & Wound Care

Question 1

Braden Assessment Categories

Answer 1

1. Sensory Perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction & Shear

Question 2

What rating on Braden Assessment indicates at risk for pressure ulcers?

Answer 2

<18

Question 3

Stage 1 Pressure Injury

Answer 3

skin is intact
nonblanchable redness
swollen tissue
darker skin (may appear blue/purple)

Question 4

Stage 2 Pressure Injury

Answer 4

skin is NOT intact
partial thickness loss
no fatty tissue is visible
superficial ulcer

Question 5

Stage 3 Pressure Injury

Answer 5

skin is NOT intact
full thickness SKIN loss
-damage to or necrosis of subQ tissue
-no bone, muscle, or tendon exposed
ulcer extend down to underlying fascia, but not through it
deep crater with or without tunneling

Question 6

Stage 4 Pressure Injury

Answer 6

skin is NOT intact
full thickness TISSUE loss
-destruction of tissue
-bone, muscle or tendon exposed
deep pockets of infection and tunneling

Question 7

Deep Tissue Injury (DTI)

Answer 7

skin is intact (unbroken)
tissue beneath the surface is damaged
appears purple or dark red

Question 8

Unstageable Pressure Injury

Answer 8

stage cannot be determined due to eschar or slough covering the visibility of the wound

Question 9

Serous Wound Drainage

Answer 9

primarily clear or straw in color
watery consistency

blister, superficial cut

Question 10

Sanguineous Wound Drainage

Answer 10

contains RBCs
looks like blood

deep wounds, surgical wounds

Question 11

Serosanguineous Wound Drainage

Answer 11

mixture of serum and RBCs
pink-tinged in color
thin and watery

sign of HEALING

Question 12

Purulent Wound Drainage

Answer 12

made of WBCs, dead tissue debris, dead and living bacteria
brown, tan, green, yellow in color
thick milky consistency

considered an ABNORMAL finding (sign of INFECTION)

may also see fever, heat, swelling, redness, tender, increase pain

Question 13

Abscess

Answer 13

collection of infected fluid that has not drained

Question 14

Dehiscence

Answer 14

separation of layers of surgical wound

Question 15

Desiccation

Answer 15

dehydration; process of being rendered free from moisture

Question 16

Epithelialization

Answer 16

stage of wound healing in which epithelial cells form across the surface of a wound

Question 17

Evisceration

Answer 17

protrusion of viscera through an incision

COMPLETE SEPARATION OF WOUND

Question 18

Fistula

Answer 18

abnormal passage from an internal organ to the skin or from one internal organ to another

Question 19

Granulation Tissue

Answer 19

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

red/beefy looking

Question 20

Hematoma

Answer 20

localized mass of usually clotted blood

Question 21

Ischemia

Answer 21

deficiency of blood in a particular area

Question 22

Maceration

Answer 22

softening through liquid; OVERHYDRATION

Question 23

Ecchymosis

Answer 23

bruising

Question 24

Wound Healing Phases

Answer 24

1. Hemostasis (bleeding, clear fluid, start of scabbing)
2. Inflammatory Phase (acute inflammation)
3. Proliferation Phase (granulation tissue forms)
4. Maturation Phase (wound starts to look like adjacent tissue)

Question 25

Wound Complications

Answer 25

Infection (bacteria enters wound area)
Hemorrhage (bleeding)
Dehiscence (splitting of wound)
Evisceration (complete separation of wound)
Fistula Formation

Question 26

Dehiscence vs. Evisceration

Answer 26

D - separation or splitting open of layers of a surgical wound

E - extrusion of viscera or intestine through a surgical wound

Question 27

Appearance of the Wound Characteristics

Answer 27

location
size (mm)
approximation of wound edges
peri-wound (around wound)
color

Question 28

Wound Care/Dressing Changes

Answer 28

1. Remove Dressing (gentle, edges first, pull in dir. of hair growth, stabilize skin while pulling tape back)
2. Clean Wound (gentle, use mechanical/chemical force to remove debris, irrigate wound w/ what’s ordered)
3. Apply Dressing (apply skin layer around wound (vaseline), ensure dressing is only on wound)
4. Secure Dressing (self-adhesive (when possible), gauze roll, bandages, tape)

Question 29

Dry Heat Therapy

Answer 29

bags of hot water
heating pads
hot packs

Question 30

Moist Heat Therapy

Answer 30

warm washcloths
warm soaks
sitz bath (perineal area)

Question 31

Dry Cold Therapy

Answer 31

ice bags
cold packs
frozen vegetables

Question 32

Moist Cold Therapy

Answer 32

cool washcloths
lukewarm baths (soaks/sitz bath)