Ch 35- Skin Integrity & Wound Healing

Question 1

Maceration

Answer 1

softening and breaking down of skin resulting from prolonged exposure to moisture

Question 2

Dehiscence

Answer 2

splitting or bursting open of a pod or wound (no organs coming out)

• Separation of one or more layers of wound tissue

Question 3

Evisceration

Answer 3

uncontrolled exteriorization of intraabdominal contents through the dehisced surgical wound outside of the abdominal cavity.
(Organs coming out of wound)

Question 4

Integumentary system

Answer 4

• largest organ of the body
• protects internal organs
• Helps maintain health and wellness

Question 5

Braden scale -

The results guide plan of care to prevent skin breakdown

Answer 5

• focused assessment
• targets high risk clients
• assigned risk score based on
• sensory perception
• moisture
• activity
• mobility
• nutrition
• friction
• shear

Question 6

Common interventions for wound prevention

Answer 6

• keeping skin free of irritants
• keeping skin clean
• optimizing nutrition and hydration
• repositioning
• massaging

Question 7

Existing wound assessment

they have an existing wound

Answer 7

Document:
-Location (in anatomical terms)

• size (length, width, depth)
• appearance (Open or closed, sutures, wound color, condition of wound bed, skin around wound)
• drainage (Color, consistency, amounts, odor)
• patient responses (pain, discomfort, itching)

Question 8

Eschar

Answer 8

is a collection of dead tissue within the wound that is flush with skin surface. Thick, hard, and black and brown

Aka
unstageable pressure injury

Question 9

Slough

Answer 9

Tan, Yellow, gray, green, or brown necrotic tissue in the wound bed

it is usually wet, but can be dry

Usually soft, stringy, and pale yellow or gray

Question 10

Exudate

Answer 10

Drainage

Question 11

Xerosis

Answer 11

Dry skin

Rough, dry skin with that may have scales or small cracks.

Question 12

Ischemia

Answer 12

Lack of oxygen to area

Question 13

Superficial wounds

Answer 13

Involve only the epidermal layer of the skin. The injury is usually the result of friction, shearing, or burning.

Question 14

Partial thickness wounds

Answer 14

Extend through the epidermis but not through the dermis

Question 15

Full thickness wound

Answer 15

Extend into the subcutaneous tissue and beyond, (potentially to the bone)

Question 16

Phases of healing

Answer 16

*Inflammatory phase- cleansing
(two major processes: hemostasis and inflammation) 1-5 days

• proliferative phase - granulation
  (fibroblasts migrate to the wound where they form collagen) 5-21 days
• maturation phase - epithelialization
  (Aka remodeling phase) scar tissue
  3-6 months

Question 17

Epithelialization

Answer 17

Phase of wound healing that describes collagen fibers breaking down and remodeling

Question 18

Primary causes of maceration

Answer 18

• fever

- incontinence

Question 19

What Types of scheduled hygiene are provided in healthcare facilities?

Answer 19

• hourly rounds
• early morning care
• morning care
• afternoon care
• hour of sleep care

Question 20

PICOT

Answer 20

Pressure injury and the poorly nourished older adult

Question 21

Excoriation

Answer 21

Superficial wound, usually self-inflicted due to excessive scratching or mechanical force

Question 22

Contusion

Answer 22

A closed wound caused by blunt trauma, may be referred to as a bruise or ecchymotic area

Question 23

Phases of healing

Answer 23

• Inflammatory phase - cleansing
• proliferative phase -granulation
• maturation phase - epithelialization

Question 24

Types of healing

Answer 24

-regenerative/epithelial healing: occurs when a wound affects only the epidermis and dermis, no scar.

-primary intention healing:
Has edges that will approximate closed, no tissue loss

-secondary intention healing:
When there is tissue loss, and the wound edges are not able to close together.

-Tertiary intention healing: aka delayed primary closure, occurs when two surfaces of granulation tissue are brought together.

Question 25

Ischemia

Answer 25

an inadequate blood supply to an organ or part of the body, especially the heart muscles.

Question 26

Assessing for and evaluating pressure injury

Answer 26

• Braden scale: Predicting Pressure Ulcer Risk
• Norton scale: predict the likelihood a patient will develop pressure ulcers
• PUSH tool: monitors three parameters: surface area of the wound, wound exudate and type of wound tissue. Wounds are measured using a centimeter ruler.