CH 33/55 Skin Integrity and wound care

Question 1

Wounds are the results of

Answer 1

injury to the skin

Question 2

Although there are many different methods and degrees of wound injury

Answer 2

the basic phases of healing are essentially the same for most wounds

Question 3

A pressure injury is

Answer 3

a specific type of tissue injury from unrelieved pressure usually over bony prominences that results in ischemia and damage to the underlying tissue

Question 4

stages of wound heal thing

Answer 4

Inflammatory stage, proliferative stage, maturation or remodeling stage

Question 5

Inflammatory stage(1)

Answer 5

Begins with injury and last 3 to 6 days

Question 6

Proliferative Stage(2)

Answer 6

last 3-24 days replacing lost tissues resurfacing new epithelial cells

Question 7

Maturation or remodeling stage (3)

Answer 7

occurs on about day 21 and involves the strengthening of the collage scar it can take more than 1 year to complete

Question 8

Primary Intention

Answer 8

little to no tissue loss, edges approximated with surgical incision. heals rapidly, low infection risk, minimal scarring

Question 9

Example of primary intention

Answer 9

closed surgical incision with staples. sutures, or liquid glue

Question 10

Secondary intention

Answer 10

loss of tissue, wound edges separated, longer healing, increase infection risk, scarring, heals by granualation

Question 11

Secondary intention example

Answer 11

pressure injury left open to heal

Question 12

Tertiary intention

Answer 12

widely separated, deep, risk of infection, closed later,

Question 13

Tertiary Intention example

Answer 13

abdominal wound initially left open until infection is resolved and then closes

Question 14

Factos affecting wound healing

Answer 14

age, overall wellness, decrease leukocyte count, infection, meds such as anti-inflammatory and antineoplastic. malnourshed clients, tissue perfusion, low hgb levels, obesity, chronic diseases, smoking, wound stress

Question 15

Note the appearance of

Answer 15

open wounds

Question 16

red wound

Answer 16

healthy regeneration of tissuey

Question 17

yellow wound

Answer 17

present of purulent drainage and slough

Question 18

black wound

Answer 18

present of eschar that hinders healing and requires removal

Question 19

USE RYB color code guide for wound care

Answer 19

red-cover
yellow-clean
black-deride, remove necrotic tissue

Question 20

closed wounds

Answer 20

skin edges should be well approximated

Question 21

drainage

Answer 21

aka exudate

Question 22

drainage (exudate)

Answer 22

A result of the healing process and accumales during the inflammatory and proliferative phases

Question 23

Note the amount, color, consistency of wound

Answer 23

drainage

Question 24

For an accurate measurement of drainage weigh the dressing

Answer 24

1g=1ml of drainage

Question 25

Serous drainage

Answer 25

the portion of the blood that is watery and clear or slightly yellow In color

Question 26

example of serous drainage

Answer 26

drainage from blisters

Question 27

Sanguineous drainage

Answer 27

contains serum and red blood cells. thick and appears reddish. brighter drainage indicated bleeding, darker indicated older bleeding

Question 28

serosangueneous drainage

Answer 28

contains both serumm and blood. water and pale and pink due to a mix of red and clear fluid

Question 29

purulent drainage

Answer 29

result of infection. thick and contains white blood cells, tissue debris, and bacteria. maybe could odor and its color yellow, tan, green, brown reflect the type of organic,

Question 30

purosanguineous

Answer 30

a mixed drainage of pus and blood (newly infected wound)

Question 31

Ensure adequate hydrate

Answer 31

2,500 ml of fluid a day if no heart and kidney issues

Question 32

Educate about good protein sources

Answer 32

meat, poultry, eggs, dairy, beans, nuts, whole grains

Question 33

for clean wounds such as a surgical incision clean

Answer 33

from least contaminated (the incision) toward the most contaminated ( the skin)

Question 34

Do not use cotton balls or other fibers that shed

Answer 34

to clean wounds

Question 35

wound dressings

Answer 35

woven gauze, nonadherant, damp to damp, self adhesive transparent film, hydrocolloid, hydrogel, alginates, collagen

Question 36

Woven gauze drssing

Answer 36

absorbs exudate from wound

Question 37

nonadherant material

Answer 37

does not stick to the wound bed

Question 38

damp to damp dressing

Answer 38

used to mechanically debride a wound until granulation tissue starts to form must keep moist

Question 39

self adhesive transparent film

Answer 39

a temporary second skin ideal for small superficial wounds

Question 40

hydrocolloid

Answer 40

an occlusive dressing that swells in the presence of exudate,

Question 41

hydrogel

Answer 41

mostly water felt after contact with exudate , moist wound bed

Question 42

alginates

Answer 42

non adherent dressing conform to wound shape and absorb exudate packs wound supports debridement

Question 43

collage

Answer 43

powders pastees granules sheets, hells, helps stops bleeding, promotes healing

Question 44

vacuum assisted closure system

Answer 44

use of foam strips laid into the wound bed with a sealed drape applies and suction tubing placed speeds tissue generation and decrease swelling

Question 45

Dehiscent

Answer 45

a partial or Toal rupture separation of a sutured round

Question 46

evisceration

Answer 46

a dehiscent that involves the protrusion of visceral organs through a wound opening

Question 47

Deep tissue pressure injury

Answer 47

persistent non blanchable, deep red, maroon, or purple discoloration

Question 48

stage 1 pressure injury

Answer 48

non blancahble erythema of intact skin

Question 49

stage 2 pressure injury

Answer 49

partial thickness skim loss with exposed dermis, involves epidermis and dermis. Wound bed is viable with reddish-pinikish bed without slough, eschar, granulaiton or adipose tissue. it can appear as an intact or ruptured blister

Question 50

stage 3 pressure injury

Answer 50

full thinkness ki loss, visible adipose tissue and possible granulation tissue. wound edges appear roller under, slough, eschar present. no exposed muscle tendons ligaments cartilage or bones. possible tunneling

Question 51

stage 4 pressure injury

Answer 51

full thickness skin and tissue loss with cartilage bone fascia, muscle tendon exposed.un

Question 52

unstageable press injury

Answer 52

obscured, full thickness skin and tissue loss. No determination of stage because escharor slough obscures the wound bed.

Question 53

To avoid pressure injuries keep bed

Answer 53

at or below 30 degrees

Question 54

to avoid pressure injuries

Answer 54

reposition client in bed every 1-2 hours

Question 55

Keep an eye on _____ levels for skin

Answer 55

albumin 3.5

Question 56

Pressure injury stage 1 treatment

Answer 56

relieve pressure, turning, keep clean

Question 57

pressure injury stage 2 treatment

Answer 57

moist healing environment,hydrocolloid dressing

Question 58

stage 3 pressure injury treaten=ment

Answer 58

clean or deride

Question 59

stage 4 pressure injury treatment

Answer 59

clear or deride- non ahdheran dressing changes every 12 hours, skin grafts