Exam 2 - Chapter 32 (Skin Intergity and Wound Care)

Question 1

Functions of the Skin - Protection

Answer 1

Acts as a barrier to water. REquires intact skin and mucous membranes to defend against pathogens

Question 2

Functions of the Skin - Temperature Regulation

Answer 2

Draws heat from the skin as perspiration occurs and evaporates

Question 3

Functions of the Skin - Sensation

Answer 3

Provides sense of touch, pain, pressure, and temperature through million of nerve endings

Question 4

Functions of the Skin - Vitamin D Production

Answer 4

Activated from UV rays from sun to produce Vitamin D

Question 5

Functions of the Skin - Immunologic

Answer 5

Triggers immunologic repsonses when broken

Question 6

Functions of the Skin - Absorption

Answer 6

Absorbs substances, such as medications, for local and systemic effects

Question 7

Functions of the Skin - Elimination

Answer 7

Secretes small amounts of water, electrolytes, and nitrogenous wastes in sweat

Question 8

All functions of skin?

Answer 8

Protection
Body Temperature
Sensation
Vitamin D Production
Immunologic
Absorption
Elimination

Question 9

Factors Affecting the Skin

Answer 9

Mobility
Nutritional Status
Age
Illness
Circulation
Moisture
Incontinence

Question 10

Wound

Answer 10

A break or disruption in the normal integrity of the skin and tissues

Question 11

What are some different ways that wounds can be classified?

Answer 11

Intentional/Unintentional
Open/Closed
Acute/Chronic
Pressure Ulcers

Question 12

Open Wounds

Answer 12

Can be intentional or unintentional; skin is broken

Question 13

Closed Wounds

Answer 13

Intact Skin with soft tissue damage

Question 14

Hematoma

Answer 14

Collection of blood outside the vessel

Question 15

Ecchymosis

Answer 15

Bruising

Question 16

Pressure Ulcers can be classified into what categories?

Answer 16

Partial Thickness
Full Thickness
Complex

Question 17

Pressure Ulcers - Partial Thickness

Answer 17

All or a portion of the dermis is intact

Question 18

Pressure Ulcers - Full Thickness

Answer 18

Entire dermis and sweat glands and hair follices are severed, which can expose bone, tendon, or muscle

Question 19

Pressure Ulcers - Complex

Answer 19

A full-thickness loss the true depth cannot be determined

Question 20

Incision

Answer 20

Cutting or shape instrument, wound edges in close approximation and aligned

Question 21

Contusion

Answer 21

Blunt instrument,overlying skin remains intact

Question 22

Abrasion

Answer 22

Friction; rubbing or scraing with top layer abraded

Question 23

Laceration

Answer 23

Tearing of skin and tissue with blunt or irregular instrument

Question 24

Puncture

Answer 24

Blunt or shape object puncturing the skin

Question 25

Penetrating

Answer 25

Foreign object entering the skin or mucous membrane and lodging in underlying tissue

Question 26

Avulsion

Answer 26

Tearing a structure from normal anatomic position

Question 27

Chemical

Answer 27

Toxic agents such as drugs, acids

Question 28

Thermal

Answer 28

High or lowtemperatures

Question 29

Pressure Ulcers

Answer 29

Compromised circulatioon secondary to pressure or pressure combined with friction

Question 30

Venous Ulcers

Answer 30

Injury and poor venous return

Question 31

Arterial Ulcers

Answer 31

Injuries and underlying ischemia

Question 32

Diabetic Ulcers

Answer 32

Injury and underlying diabetic neuropathy

Question 33

Four Stages of wound healing?

Answer 33

Hemostasis, Inflammation, Proliferation, and Maturation

Question 34

Hemostasis occurs..

Answer 34

immediately after the initrial injury. Involved blood vessels constrict and blood clotting begins through platet activation and clustering

Question 35

How do pressure/edema affect wound healing?

Answer 35

Disrupt blood flow of oxygen and nutrients to the wound

Question 36

Local Factors Affecting Wound Healing - Desiccation

Answer 36

Cells dry and die , moist wound bed promotes epitheliazation

Question 37

Local Factors Affecting Wound Healing - Maceration

Answer 37

Cells burst due to overhydration

Question 38

Local Factors Affecting Wound Healing - Infection

Answer 38

Decreases available energy in the body for skin repair

Question 39

Local Factors Affecting Wound Healing - Necrosis (Slough)

Answer 39

Moist, yellow, stringy tissue

Question 40

Local Factors Affecting Wound Healing - Necrosis (Eschar)

Answer 40

Dry, black, leathery tisue

Question 41

Dehisence

Answer 41

Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

Question 42

Evisceration

Answer 42

Is the most serious complication of dehisence. Abdominal wound completely separates, with protrusion of visceria through the incisional area

Question 43

Stage I Pressure Ulcer

Answer 43

Non-Blachable Erythema of intact skin

Question 44

Stage II Pressure Ulcer

Answer 44

Partial-Thickness Skin Loss

Question 45

Stage III Pressure Ulcer

Answer 45

Full-thickness skin loss; not involving underlying fascia

Question 46

STage IV Pressure Ulcer

Answer 46

Full-thickness skin loss with extensive destruction

Question 47

Unstageable Pressure Ulcer

Answer 47

Base of ulcer covered by slough and or eschar in wound bed

Question 48

Fistula

Answer 48

Is an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another

Question 49

Pressure Injury

Answer 49

Defined as localized damage to the skin and underlying tissue that usually occurs over a body prominence

Question 50

Open Would Classification - R

Answer 50

Red - Protect

Question 51

Open Would Classification - Y

Answer 51

Yellow - Cleanse

Question 52

Open Would Classification - B

Answer 52

Black - Debride

Question 53

Open Would Classification - Mixed Wound

Answer 53

Contains components of RY&B wounds

Question 54

What is the main purpose of wound dressings?

Answer 54

TO prevenet disease, and promote healing

Question 55

Serious Drainage

Answer 55

Composed primarily of the clear, serious portion of the blood and from serous membranes. Clear and Watery

Question 56

Sanguineous Drainage

Answer 56

Consists of large numbers of red blood cells, and look slike blood. Bright-red sanguineous draingage is indicative of fresh bleeding

Question 57

Serosanguineous Drainage

Answer 57

Mixture of serum and red blood cells. It is light pink to blood tinged

Question 58

Purulent Drainage

Answer 58

MAde up of white blood cells, liquefied dead tissue debris and both dead and live bacteria.

Question 59

Types of Wound Dressings?

Answer 59

Telfa Gauze Dressing TRansparent Dressing

Question 60

Topics for Home HEalth Care Teaching

Answer 60

``` Supplies Infection Prevention Wound Healing Appearance of the Skin/Recent Changes Activity/Mobility Nutrition Pain ```

Question 61

Effects of Applying Heat?

Answer 61

``` Dilates peripheral blood vessels Increases tissue metabolism Reduces blood viscosity REduces muscle tension Helps relieve pain ```

Question 62

Effects of Applying Cold?

Answer 62

Constricts peripheral blood vessels Reduces muscle spasms Promotes comfort