Chapt 36- skin and wounds

Question 1

Layers of skin

Answer 1

Epidermis, Dermis and Subcutaneous layer

Question 2

Factors influencing Skin Integ

Answer 2

Nutrition, tissue perfusion, infection, age, mobility, cognition, moisture, medications

Question 3

Sensation/cognition

Answer 3

diabetic nephropathy can be caused due to diabetics and getting edema

Question 4

Venous Circulation

Answer 4

engorged tissue with a lot of waste products and results in edema, skin b.down and ulceration

Question 5

Skin

Answer 5

Tanning, hygiene habit, diet, smoking

Question 6

Types of wound

Answer 6

• length of time
• condition
• depth

Question 7

Chronic

Answer 7

Heal from inside out

Question 8

Wound healing- 3 types

Answer 8

Primary, Secondary, Tertiary

Question 9

Primary Healing

Answer 9

Very clean wound usually via sutures and no scar

Question 10

Secondary Healing

Answer 10

Wound can’t be brought together due to a lot of tissue lose

-no sutures work and SCAR

Question 11

Tertiary Healing

Answer 11

• Wound edges are together(approximated)
• Used in BIG surgical wounds that are complicated by infection
• ex : abdominal and knee surgeries
• very wide scar

Question 12

Phases of healing

Answer 12

inflam, proliferative and maturation

Question 13

Complications

Answer 13

Dehiscence- separate or splitting open of layers of surgical wound
Evisceration- extrusion of viscera or intestine through surgical wound

Question 14

Wound Draining

Answer 14

Serous Exudate, Sanguineous Exudate, Serosanguienous, prulent exudate, Purosanguienous exudate

Question 15

Pressure Ulcer- Time and Pressure are the key variables in Ischemia

Answer 15

Time and Pressure- Large pressure for a short amount of time, or lighter pressure for an extended period of time.

Question 16

Foot drop

Answer 16

Pt that stays in bed, their muscles and tendons will stay that way

• need to be moved and exercised
• boots are used to keep feet in position and their heal DOES NOT touch anything (take on and off)
• while off- put pillow from knee to ankle and heal should be in air = no PRESSURE

Question 17

What can cause when a pt is bed bound

Answer 17

Shear and friction

Question 18

Protective Mech for ischemia

Answer 18

Normal hyperemia- flush of blood flow to ischemic area and redden

Abnormal hyperemia- excessive vasodilation of tissue with induration (harderning

Question 19

Stages of Pressure Ulcers

Answer 19

S1- localized, non-blanchable, red, over bony area.
-warm or cool and discoloration returns in 30 min
S2-open, pink, partial thickness, slough, blister/shiny or dry with slough and bruise
S3-Full thickness, necrosis to subcut but no bone visible
S4- exposed BONE/TENDON, necrosis, slough

Question 20

Additional Pressure Ulcer Formations

Answer 20

Suspected Deep Tissue- skin intact, boggy, bruising or blister present
Unstageable Pressure Ulcer- full thicknness, wound has slough and eschar(black/brown): dont remove it