Exam 2 module 3 part 5 Flashcards

Question

What happens to the skin texture of children as they age?

Answer 1

Becomes coarser due to exposure to sun and environmental elements ## Footnote Infants and young children initially have smooth skin

Answer 2

Increased sex hormones lead to sebaceous and sweat gland activity ## Footnote This can result in perspiration, odor, and acne

Answer 3

Softening of connective tissue, striae, and darkening of the skin ## Footnote Commonly seen on the face, areolae, nipples, vulva, and umbilicus

Answer 4

Xerosis ## Footnote Characterized by itchy, red, dry, scaly, cracked, or fissured skin

Answer 5

Loses elasticity due to collagen changes ## Footnote This increases the risk of skin breakdown and prolongs wound healing

Answer 6

Regeneration of healthy skin and healing is significantly slower ## Footnote Chronic diseases in older adults can further interfere with healing

Answer 7

* Diabetes * Liver dysfunction ## Footnote These conditions can predispose to infections and affect blood-clotting factor synthesis

Answer 8

Inability to move independently or lack of sensation ## Footnote Pressure from the body weight can lead to skin tissue injury

Answer 9

* Paralysis * Extreme fatigue * High-risk pregnancy * Sedation * Casts * Traction * Altered sensory perception ## Footnote These conditions can prevent movement and increase pressure on the skin

Answer 10

A person’s overall nutritional status ## Footnote Nutritional intake affects the skin.

Answer 11

Adequate intake of protein, cholesterol, calories, fluid, vitamin C, and minerals ## Footnote These nutrients contribute to skin health.

Answer 12

It maintains the skin, repairs minor defects, and preserves intravascular volume ## Footnote Adequate protein levels are critical for skin health.

Answer 13

* Skin injury is slow to heal * Minor defects cannot be repaired * Edema develops ## Footnote Fluid leaks from the vascular compartment of dependent areas.

Answer 14

* Decreases skin elasticity * Interferes with oxygen diffusion * Prone to breakdown ## Footnote Edema is excess fluid in the tissues.

Answer 15

Predisposes patients to skin breakdown and inhibits wound healing ## Footnote Low-fat tube feedings may lead to deficiencies.

Answer 16

Provide fuel for wound healing and maintain a waterproof barrier in the stratum corneum ## Footnote Cholesterol, fatty acids, and linoleic acid are important.

Answer 17

The body uses proteins for energy, making them unavailable for building and maintenance functions ## Footnote This leads to catabolism.

Answer 18

* Weight loss * Loss of subcutaneous tissue * Muscle atrophy * Decreased padding between skin and bones ## Footnote This predisposes skin to pressure injuries.

Answer 19

* Vitamin C (ascorbic acid) * Zinc * Copper ## Footnote A deficiency can delay wound healing.

Answer 20

Dehydration ## Footnote Skin turgor reflects the hydration status of the skin.

Answer 21

Overhydration ## Footnote Both dehydrated and edematous skin are prone to injury.

Answer 22

* Pressure * Shearing * Friction * Moisture ## Footnote Both dry and overhydrated skin are at risk.

Answer 23

Pressure injury

Answer 24

Immobility, friction, shear, postoperative drainage

Answer 25

Malnourished adults

Answer 26

Nutritional supplements

Answer 27

Diet without supplements

Answer 28

Improved (or faster) healing time

Answer 29

A reduced ability to sense touch, heat, and pressure in affected areas ## Footnote Patients with conditions like peripheral vascular disease, spinal cord injury, diabetes, cerebrovascular accident, trauma, or fractures often experience diminished tactile sensation.

Answer 30

Increased risk of skin breakdown, burns, unnoticed cuts or wounds, and inability to feel pressure ## Footnote Patients may not shift position to relieve pressure or notice constricting footwear or clothing.

Answer 31

Increased risk due to lack of awareness of the need to reposition ## Footnote Conditions such as Alzheimer disease and dementia can lead to cognitive impairment.

Answer 32

Restriction of activity, production of pain, and muscle atrophy due to reduced blood flow ## Footnote Impaired arterial circulation can result in thin tissue that may lead to tissue death.

Answer 33

Engorged tissues with high levels of metabolic waste, leading to edema, ulceration, and breakdown ## Footnote This occurs when blood flow back to the heart is inadequate.

Answer 34

Circulatory impairment ## Footnote Both arterial and venous circulation issues interfere with tissue metabolism and delay wound healing.

Answer 35

hot surface

Answer 36

Talk to families or caregivers and review the patient's health history ## Footnote This helps adjust the plan of care.

Answer 37

* Peripheral vascular disease * Spinal cord injury * Diabetes * Cerebrovascular accident * Trauma * Fractures

Answer 38

Tissue becomes engorged, susceptible to edema, ulceration, and breakdown

Answer 39

Medications can cause pruritus, dermatoses, photosensitivity, alopecia, or pigmentation changes ## Footnote These effects can impair skin integrity or delay healing.

Answer 40

They decrease the amount of pressure required to occlude blood flow, creating a risk for ischemia ## Footnote Ischemia is insufficient blood supply to tissues.

Answer 41

They inhibit wound healing ## Footnote Examples include over-the-counter NSAIDs and steroids like prednisone.

Answer 42

They can lead to extravasation of blood into subcutaneous tissue, causing hematomas ## Footnote Anticoagulants include heparin and warfarin.

Answer 43

Chemotherapeutic agents ## Footnote Methotrexate is an example.

Answer 44

Certain antibiotics, psychotherapeutic drugs, and chemotherapy agents ## Footnote This increases the risk for sunburn.

Answer 45

Stevens-Johnson syndrome ## Footnote This condition is characterized by severe rash and skin peeling.

Answer 46

cleanse ## Footnote These products can cleanse the skin while also leading to dryness.

Answer 47

Leads to maceration and increases the likelihood of skin breakdown ## Footnote Maceration refers to the softening of the skin due to prolonged moisture exposure.

Answer 48

Incontinence and fever ## Footnote Bowel incontinence is particularly troublesome due to the presence of digestive enzymes and microorganisms.

Answer 49

Can lead to excoriation, moisture-associated skin damage, dermatitis, pressure injury, and infection ## Footnote Excoriation refers to the denuding of superficial skin layers.

Answer 50

Leads to sweating and increases metabolic rate, raising tissue demand for oxygen ## Footnote Increased oxygen demand is especially problematic with circulatory impairment or pressure-induced tissue compression.

Answer 51

Presence of microorganisms in the wound ## Footnote All chronic wounds are considered contaminated.

Answer 52

Microorganisms increase in number but cause no harm ## Footnote Colonization can occur from surrounding skin, the external environment, and internal sources like the GI system.

Answer 53

When bacteria begin to overwhelm the body’s defenses ## Footnote Signs include increased drainage, foul odor, color change of the wound bed, new tunneling, or absent/friable granulation tissue.

Answer 54

Microorganisms are causing harm by releasing toxins, invading tissues, and increasing metabolic demand ## Footnote Infection makes the skin more vulnerable to breakdown and impedes healing.

Answer 55

True ## Footnote If not controlled, bacteria can enter the bloodstream.

Answer 56

Increases the risk for skin cancer and drying the skin ## Footnote Tanning exposes the skin to ultraviolet radiation.

Answer 57

May impair skin integrity and lead to drying ## Footnote Frequent bathing and use of soap remove skin oils.

Answer 58

Contributes to excessive oiliness, clogged sebaceous glands, and inadequate removal of microbes ## Footnote This can lead to infections on wounds or lesions.

Answer 59

Improves circulation, necessary for skin integrity and wound healing ## Footnote Circulation is vital for delivering nutrients and oxygen to skin tissues.

Answer 60

Provides nutrients needed to maintain skin integrity ## Footnote Nutrients are essential for skin repair and health.

Answer 61

Compromises oxygen supply, delays wound healing, and interferes with vitamin C absorption ## Footnote Vitamin C is necessary for collagen formation.

Answer 62

Risk for infection and scarring ## Footnote Common complications include local inflammation, allergic reactions, and skin infections.

Answer 63

Staphylococcus and Pseudomonas strains ## Footnote These bacteria are often found at or near the site of body piercings.

Answer 64

Hepatitis C ## Footnote Unsterile conditions can lead to serious infections.

Answer 65

Gingivitis, damage to teeth and gums, choking, difficulty eating, and changes in speech ## Footnote Oral piercings can lead to various oral health issues.

Answer 66

A punctured blood vessel ## Footnote Prolonged bleeding can be a serious complication.

Answer 67

Become informed about the procedure and aftercare, and find reputable tattoo artists/piercers ## Footnote Knowledge and safety are key to minimizing risks.

Answer 68

A disruption in the normal integrity of the skin ## Footnote Wounds may be intentional (surgical) or unintentional (cuts, pressure injuries)

Answer 69

According to length of time and condition of the wound ## Footnote Factors include contamination and severity

Answer 70

No breaks in the skin ## Footnote Examples include contusions and tissue swelling from fractures

Answer 71

A break in the skin or mucous membranes ## Footnote Includes abrasions, lacerations, puncture wounds, and surgical incisions

Answer 72

A fracture that leads to an open wound caused by the projection of bone through the skin ## Footnote This type of injury can create significant complications

Answer 73

Wounds expected to be of short duration that heal spontaneously ## Footnote They go through three phases: inflammation, proliferation, and maturation

Answer 74

Wounds that exceed the expected length of recovery due to interrupted healing ## Footnote Examples include pressure injuries and diabetic ulcers

Answer 75

* Infection * Continued trauma * Ischemia * Edema ## Footnote These factors can lead to prolonged recovery times

Answer 76

Uninfected wounds with minimal inflammation ## Footnote They may be open or closed and do not involve certain tracts that harbor microorganisms

Answer 77

False ## Footnote Clean wounds do not involve these systems, which frequently harbor microorganisms

Answer 78

months ## Footnote Unless properly diagnosed and treated, chronic wounds can persist for long durations

Answer 79

A scrape of the superficial layers of the skin; usually unintentional but may be performed intentionally for cosmetic purposes to smooth skin surfaces. ## Footnote Also see excoriation.

Answer 80

A localized collection of pus resulting from invasion from a pyogenic bacterium or other pathogen; must be opened and drained to heal.

Answer 81

A closed wound caused by blunt trauma; may be referred to as a bruise or an ecchymosis.

Answer 82

A wound caused by force leading to compression or disruption of tissues, often associated with fracture; usually minimal or no break in the skin.

Answer 83

A superficial wound, usually self-inflicted due to excessive scratching or mechanical force.

Answer 84

An open, intentional wound caused by a sharp instrument.

Answer 85

The skin or mucous membranes are torn open, resulting in a wound with jagged margins.

Answer 86

An open wound in which the agent causing the wound lodges in body tissue.

Answer 87

An open wound caused by a sharp object; often there is collapse of tissue around the entry point, making this wound prone to infection.

Answer 88

A wound with entrance and exit sites.

Answer 89

Surgical incisions that enter the GI, respiratory, or genitourinary tracts with increased risk of infection but no obvious infection. ## Footnote These wounds are at risk due to their nature of entering areas that are normally not sterile.

Answer 90

Open, traumatic wounds or surgical incisions with a major break in asepsis and high risk of infection. ## Footnote Contaminated wounds often involve exposure to pathogens.

Answer 91

Wounds with bacteria above 100,000 organisms per gram of tissue. ## Footnote Presence of beta-hemolytic streptococci in any number is also considered an infection.

Answer 92

* Erythema and swelling around the wound * Fever * Foul odor * Severe or increasing pain * Large amount of drainage * Warmth of the surrounding soft tissue ## Footnote These signs indicate potential complications in wound healing.

Answer 93

Depth of the wound and location. ## Footnote Deeper wounds take longer to heal, and wounds in areas of pressure or movement heal slower.

Answer 94

Wound healing is more difficult in areas of poor circulation, such as the feet in those with diabetes or congestive heart failure. ## Footnote Adequate blood flow is essential for healing.

Answer 95

Wounds that involve only the epidermal layer of the skin, usually due to friction, shearing, or burning. ## Footnote These wounds typically heal faster than deeper wounds.

Answer 96

Wounds that extend through the epidermis but not through the dermis. ## Footnote These wounds can be more complex than superficial wounds.

Answer 97

Wounds that extend into the subcutaneous tissue and beyond. ## Footnote The term 'penetrating' may be added if internal organs are involved.

Answer 98

Epithelial cells, endothelial cells, inflammatory cells, platelets, fibroblasts ## Footnote Fibroblasts are cells in connective tissue that produce fibrin.

Answer 99

To produce fibrin ## Footnote Fibrin is essential for tissue repair and regeneration.

Answer 100

No, the process is essentially the same regardless of the type of injury or tissues involved.

Answer 101

To assist in tissue repair and regeneration

Answer 102

* Epithelial cells * Endothelial cells * Inflammatory cells * Platelets * Fibroblasts

Answer 103

Tissue repair and regeneration

Answer 104

Pressure, shear, and friction resulting in tissue ischemia and injury ## Footnote Pressure injuries are often located over bony prominences and can lead to serious tissue damage.

Answer 105

Located over lower leg, especially ankles, toes, side of foot, and shin; appears 'punched out', small and round with smooth borders; wound base usually pale; shiny, thin, dry surrounding skin; cool to touch; loss of hair in surrounding area; delayed capillary refill time; very painful, especially at night and with increased activity ## Footnote Arterial ulcers are caused by inadequate circulation of oxygenated blood to the tissue.

Answer 106

Around the inner ankle or in the lower part of the calf ## Footnote Venous stasis ulcers are caused by incompetent venous valves, deep vein obstruction, or inadequate calf.

Answer 107

Shiny, thin, and dry; cool to touch ## Footnote This characteristic is due to inadequate blood flow and oxygenation.

Answer 108

False ## Footnote The appearance of pressure injuries varies depending on the stage or tissue layers involved.

Answer 109

Reddened or brown surrounding skin; edematous ## Footnote These symptoms are due to fluid accumulation and poor circulation.

Answer 110

Usually pale with or without necrotic tissue ## Footnote Necrotic tissue may be present if the ulcer is severe.

Answer 111

Inadequate circulation of oxygenated blood to the tissue ## Footnote This leads to tissue ischemia and subsequent damage.

Answer 112

Pressure injury

Answer 113

Incompetent venous valves, deep vein obstruction, or inadequate calf muscle function

Answer 114

Around the inner ankle or in the lower part of the calf

Answer 115

Reddened or brown and edematous

Answer 116

Usually shallow, with irregular wound margins

Answer 117

Ruddy or beefy red and granular

Answer 118

Moderate to heavy depending on the amount of edema

Answer 119

With leg dependence and dressing changes

Answer 120

Narrowing of the arteries leading to reduced oxygenation to the feet ## Footnote This results in delayed wound healing and tissue necrosis.

Answer 121

Often painless; may include drainage, swelling, redness, and ulceration ## Footnote Symptoms may vary but often include visible signs of ulceration.

Answer 122

On the plantar surfaces and toes (balls of the foot or underside of the toes) ## Footnote These areas are prone to pressure and injury.

Answer 123

True ## Footnote This susceptibility is due to poor sensation, circulation, and immune protection.

Answer 124

[wound infection] ## Footnote Poor sensation contributes to the inability to detect injuries.

Answer 125

Regeneration, primary intention, secondary intention, tertiary intention

Answer 126

Occurs when a wound affects only the epidermis and dermis; no scar forms; new epithelial and dermal cells form skin indistinguishable from intact skin ## Footnote Partial-thickness wounds heal by regeneration

Answer 127

Healing occurs with minimal or no tissue loss and well approximated edges; little scarring expected ## Footnote A clean surgical incision is an example of primary intention healing

Answer 128

80% as strong

Answer 129

primary intention

Answer 130

Healing that occurs when a wound involves extensive tissue loss or should not be closed.

Answer 131

Extensive tissue loss.

Answer 132

When there is an infection.

Answer 133

It heals from the inner layer to the surface by filling in with granulation tissue.

Answer 134

A form of connective tissue with an abundant blood supply.

Answer 135

Small pink or pearl-like areas.

Answer 136

More prone to infection and develop more scar tissue.

Answer 137

more slowly.

Answer 138

Delayed primary closure ## Footnote Tertiary intention healing is a surgical technique used in wound management.

Answer 139

Two surfaces of granulation tissue are brought together ## Footnote This technique is applied after a period of healing by secondary intention.

Answer 140

When the wound is clean-contaminated or contaminated ## Footnote This approach is taken after initial healing by secondary intention.

Answer 141

It is allowed to heal by secondary intention ## Footnote This phase is crucial before assessing for closure.

Answer 142

No evidence of edema, infection, or foreign matter ## Footnote Ensuring these conditions helps reduce the risk of complications.

Answer 143

Strict aseptic technique ## Footnote This is necessary because these wounds are prone to infection.

Answer 144

Less scarring than secondary but more than primary intention healing ## Footnote Understanding scarring outcomes is important for patient expectations.

Answer 145

Inflammatory, proliferative, maturation

Answer 146

1 to 5 days

Answer 147

Hemostasis, inflammation

Answer 148

Blood and plasma leak into the wound, vessels constrict, platelets aggregate, and a blood clot forms

Answer 149

Edema, erythema, pain, temperature elevation, migration of white blood cells

Answer 150

Engulf bacteria (phagocytosis) and clear debris

Answer 151

Plasma proteins, fibrin, and debris

Answer 152

Seals the wound and helps prevent microbial invasion

Answer 153

[Hemostasis]

Answer 154

Occurs from days 5 to 21, where cells fill the wound defect and resurface the skin. ## Footnote This phase involves key processes like fibroblast migration and collagen formation.

Answer 155

Fibroblasts migrate to the wound and form collagen, adding strength to the healing wound. ## Footnote Fibroblasts are a type of connective tissue cell.

Answer 156

A tissue that forms during the Proliferative Phase, characterized by its ability to bleed readily and be easily damaged. ## Footnote Granulation tissue is vital for wound healing.

Answer 157

Epithelial cells begin to grow into the wound from surrounding healthy tissue, sealing over the wound (epithelialization). ## Footnote Epithelialization is crucial for restoring skin integrity.

Answer 158

It begins in the second or third week and continues even after the wound has closed. ## Footnote This phase is also known as remodeling.

Answer 159

Initial collagen fibers are broken down and remodeled into an organized structure, such as scar tissue. ## Footnote This remodeling increases the tensile strength of the wound.

Answer 160

It lasts for 3 to 6 months after the wound has closed. ## Footnote This phase is important for the final strength of the healed tissue.

Answer 161

Primary and tertiary intention ## Footnote Wound healing by primary intention involves direct closure, while tertiary intention involves delayed closure.

Answer 162

They are used for: * Closing superficial low-tension wounds * Closing the skin on wounds closed subcutaneously * Providing additional support after sutures or staples have been removed ## Footnote An example of adhesive strips is Steri-Strips.

Answer 163

superficial low-tension

Answer 164

False ## Footnote Adhesive strips can also be used after sutures or staples have been removed.

Answer 165

Aiding in healing and reducing scarring

Answer 166

Adhesive strips are often kept in place until they begin to separate from the skin on their own.

Answer 167

Sutures (stitches)

Answer 168

Small puncture wounds

Answer 169

* Absorbent sutures * Nonabsorbent sutures

Answer 170

Deep in the tissues, such as to close an organ or anastomose tissue.

Answer 171

They gradually dissolve and do not need to be removed.

Answer 172

In superficial tissues

Answer 173

Removal, usually by the nurse.

Answer 174

small puncture wounds

Answer 175

Lightweight titanium

Answer 176

Lower risk of infection and tissue reaction

Answer 177

Some wound edges are more difficult to align

Answer 178

* Arms * Legs * Abdomen * Back * Scalp * Bowel

Answer 179

Clean, low-tension wounds

Answer 180

Wound closure method for skin tears

Answer 181

Wounds that will not heal despite aggressive care

Answer 182

* Extensive débridement * Skin grafts * Flap techniques

Answer 183

Administration of 100% oxygen under pressure to a wound site

Answer 184

* Increases oxygen concentration in tissue * Stimulates growth of new blood vessels * Enhances WBC action * Promotes development of fibroblasts

Answer 185

Augments the inflammatory phase and accelerates collagen formation

Answer 186

Exudate ## Footnote Exudate is composed of serum, fibrin, and leukocytes.

Answer 187

Watery in consistency and contains very little cellular matter; consists of serum ## Footnote Serum is the straw-colored fluid that separates out of blood when a clot is formed.

Answer 188

Sanguineous exudate ## Footnote Fresh bleeding produces bright red drainage, while older, dried blood appears darker.

Answer 189

A combination of bloody and serous drainage ## Footnote It is most commonly seen in new wounds.

Answer 190

Thick, often malodorous drainage seen in infected wounds ## Footnote It contains pus, which is a protein-rich fluid filled with WBCs, bacteria, and cellular debris.

Answer 191

Pyogenic bacteria ## Footnote Examples include streptococci and staphylococci.

Answer 192

Normally yellow; can turn blue-green due to Pseudomonas aeruginosa ## Footnote Presence of this bacterium can cause a change in color.

Answer 193

Red-tinged pus ## Footnote It indicates that small vessels in the wound area have ruptured.

Answer 194

Inflammation, proliferation, maturation

Answer 195

* Hemorrhage * Infection * Dehiscence * Evisceration * Fistulas

Answer 196

Profuse or rapid loss of blood

Answer 197

Bleeding occurs

Answer 198

Cessation of bleeding

Answer 199

Within minutes

Answer 200

* Injury to large vessels * Clotting disorder * Anticoagulant therapy

Answer 201

* Slipped suture * Erosion of a blood vessel * Dislodged clot * Infection

Answer 202

In the first 24 to 48 hours

Answer 203

Swelling of the affected body part, pain, and changes in vital signs (decreased blood pressure, elevated pulse) ## Footnote Internal bleeding refers to bleeding that cannot escape to the surface, leading to a hematoma.

Answer 204

A red-blue collection of blood under the skin that forms due to bleeding that cannot escape to the surface ## Footnote A large hematoma can cause pressure on surrounding tissues.

Answer 205

It causes pressure on surrounding tissues ## Footnote If located near a major artery or vein, it may impede blood flow.

Answer 206

Bloody drainage on dressings and in wound drainage devices ## Footnote External hemorrhage is relatively easy to recognize.

Answer 207

Blood often pools underneath the patient as dressings become saturated ## Footnote It is important to look underneath the patient to assess the full extent of the bleeding.

Answer 208

During an injury, during surgery, or after surgery ## Footnote It is important to maintain sterile techniques during surgical procedures to minimize this risk.

Answer 209

A wound fails to heal ## Footnote This can be a critical sign that the body is unable to recover from the injury due to infection.

Answer 210

* Localized swelling * Redness * Heat * Pain * Fever (temperatures higher than 38°C [100.4°F]) * Foul-smelling or purulent drainage * A change in the color of drainage ## Footnote These symptoms can help healthcare providers assess the presence of an infection.

Answer 211

Within 2 to 3 days ## Footnote Early detection of these symptoms is crucial for effective treatment.

Answer 212

Usually not until the fourth or fifth postoperative day ## Footnote Understanding the timeline of infection symptoms can aid in monitoring postoperative recovery.

Answer 213

Rupture (separation) of one or more layers of a wound

Answer 214

During the inflammatory phase of healing

Answer 215

Incisions that begin draining within 5 to 7 days

Answer 216

* Poor nutritional status * Inadequate closure of the muscles * Wound infection * Increased tension on the suture line * Obesity

Answer 217

Fatty tissue does not heal readily and increased tissue mass puts strain on the suture line

Answer 218

Abdominal wounds

Answer 219

A 'pop' or tear

Answer 220

Maintaining bedrest with the head of the bed elevated at 20° and the knees flexed

Answer 221

Notify the provider of the dehiscence immediately

Answer 222

serosanguineous

Answer 223

* Coughing * Lifting an object * Sudden straining

Answer 224

Applying a binder, if necessary ## Footnote but if evisceration occurs DO NOT put a binder on a patient.

Answer 225

Total separation of the layers of a wound with internal viscera protruding through the incision ## Footnote Evisceration is considered a surgical emergency.

Answer 226

Cover the wound with sterile towels or dressings soaked in sterile saline solution ## Footnote This prevents the organs from drying out and becoming contaminated with environmental bacteria.

Answer 227

Separation of one or more layers of a wound ## Footnote Dehiscence is most common in the inflammatory phase of healing.

Answer 228

An abnormal passage connecting two body cavities or a cavity and the skin ## Footnote Fistulas are most common in the gastrointestinal and genitourinary tracts.

Answer 229

Stay in bed with knees bent to minimize strain on the incision ## Footnote This positioning helps reduce pressure on the surgical site.

Answer 230

No ## Footnote A binder can increase pressure on the wound.

Answer 231

Notify the surgeon and prepare the patient for surgery ## Footnote Immediate surgical intervention is often required.

Answer 232

An abnormal passage connecting two body cavities or a cavity and the skin.

Answer 233

Infection or debris left in the wound.

Answer 234

An abscess.

Answer 235

It breaks down, creating an abnormal passageway.

Answer 236

Skin breakdown and delayed wound healing.

Answer 237

The GI and genitourinary tracts.

Answer 238

A chronic wound is one that has not healed within the expected time frame.

Answer 239

Wounds that do not heal within 2 to 4 weeks may be considered chronic.

Answer 240

Pressure injury is a type of chronic wound.

Answer 241

Factors include time, pressure, tissue tolerance, friction, shearing, moisture, nutrition, age, circulation, and underlying health status.

Answer 242

Tissue tolerance depends on friction, shearing, moisture, and nutrition.

Answer 243

Time and pressure depend on sensation and mobility.

Answer 244

expected time frame.

Answer 245

over the bony prominences of Vertebrae, sacrum, pelvis, heels

Answer 246

parietal and temporal bones, ear, shoulder, illium, greater trochanter, knee, malleolus

Answer 247

back of head, scapulae, elbows, sacrum, heels

Answer 248

cheek and ear, shoulder, breasts, genitalia, knees, toes

Answer 249

Skin inspection, mobility, and activity assessment

Answer 250

All areas of the body for skin color, integrity, temperature, texture, turgor, mobility, moisture, lesions, and hair distribution

Answer 251

Pressure points

Answer 252

To prevent pressure injuries

Answer 253

Shoes, heel elevators, and antiembolism stockings

Answer 254

Higher risk for developing pressure injuries

Answer 255

Condition of the wound, work setting, patient’s overall condition, underlying disease process, type of wound, and type of treatment

Answer 256

With every treatment

Answer 257

In anatomical terms

Answer 258

A midsternal incision extending from the manubrium to the xiphoid process

Answer 259

Location of the wound

Answer 260

[scalp], [hands]

Answer 261

[abdomen], [heel]

Answer 262

The skin over the area is pale and cool

Answer 263

Vasodilation occurs, extra blood goes to the area, and the area flushes bright red (reactive hyperemia)

Answer 264

Tissue damage has occurred

Answer 265

Regular assessment of the skin for appearance, temperature, texture, and color

Answer 266

To detect subtle, early skin changes

Answer 267

Erythema, tenderness, or edema

Answer 268

Under breasts, in abdominal folds, and where there is skin-to-skin contact

Answer 269

Sensory perception, moisture, activity, mobility, nutrition, friction, and sheer Used for children.

Answer 270

The lower the score, the more likely the patient will develop a pressure injury

Answer 271

For children

Answer 272

Risk based on the patient's physical condition, mental state, activity, mobility, and incontinence

Answer 273

The lower the score, the higher the risk is for pressure injury

Answer 274

The progression of a pressure injury

Answer 275

Surface area, exudate, and type of wound tissue

Answer 276

The total score falls

Answer 277

Impaired Skin Integrity ## Footnote Refers to conditions where the skin is damaged or at risk of damage.

Answer 278

Actual or Risk for damage to body tissues ## Footnote Indicates potential or existing damage to tissues in the body.

Answer 279

Infection ## Footnote Can be either actual or a risk factor in wound care.

Answer 280

Pain ## Footnote A common concern in wound care management.

Answer 281

Altered Body Image ## Footnote Refers to how an individual perceives their physical self after a wound.

Answer 282

Surgery ## Footnote Includes procedures like excision, débridement, skin grafts, drains, and flaps.

Answer 283

Electrical stimulation ## Footnote Promotes healing by encouraging fibroblast development and collagen formation.

Answer 284

Hyperbaric oxygen therapy (HBOT) ## Footnote Enhances white blood cell activity to improve healing.

Answer 285

Tissue growth factors ## Footnote Important for chronic wound healing, especially in diabetic patients.

Answer 286

Ultrasound ## Footnote Aids in débridement and increases cell metabolism through vibration and heat.

Answer 287

Temporary or permanent closure of partial- and full-thickness wounds ## Footnote Made from human epidermis, dermis, animal cells, or synthetic materials.

Answer 288

Nitric oxide ## Footnote Promotes fibroblast and collagen growth for skin and tissue repair.

Answer 289

Maggot therapy ## Footnote Effective as it targets and consumes only necrotic tissue.

Answer 290

Prevention strategies ## Footnote Includes using visual cues to remind staff to implement these strategies.

Answer 291

Daily, at transfer or discharge, and if condition changes ## Footnote At-risk patients should be assessed every 8-12 hours.

Answer 292

Weekly for the first 4 weeks; then quarterly; or if condition deteriorates ## Footnote This schedule helps monitor ongoing risk.

Answer 293

With every visit ## Footnote Ensures continuous assessment of their condition.

Answer 294

Provide gentle cleansing, apply moisture barrier cream, use absorbent products ## Footnote Consider pouching systems for persistent bowel incontinence.

Answer 295

They may need frequent bathing due to sweat irritation ## Footnote Older adults typically do not require daily bathing.

Answer 296

Gently bathe with minimum force and friction ## Footnote Washcloths can be abrasive, so care is needed.

Answer 297

Mild, emollient cleansing soap ## Footnote Rinse thoroughly and gently pat the skin dry.

Answer 298

To prevent skin damage in adults at risk for pressure injury ## Footnote Especially for those with incontinent, edematous, or inflamed skin.

Answer 299

Do not massage over bony prominences ## Footnote This can irritate the area and lead to tissue injury.

Answer 300

Keep linens soft, clean, dry, and free from wrinkles ## Footnote Change them frequently to maintain skin integrity.

Answer 301

To reduce wound size using hydrocolloid or foam dressings. ## Footnote Refer to Procedure 32-8 for application details.

Answer 302

To create a vacuum that reduces edema, promotes granulation tissue formation, removes exudate and infectious material, and stimulates blood vessel growth. ## Footnote Refer to Procedure 32-6 for more information.

Answer 303

Acts as a barrier to bacteria, eliminates bacterial biofilms, and can reduce prophylactic antibiotic use. ## Footnote This helps in preventing antibiotic resistance.

Answer 304

Apply the clear film or drape free of wrinkles to create a seal for negative pressure. ## Footnote Refer to Procedure 32-7 for application guidelines.

Answer 305

Limit the angle to no more than 30°.

Answer 306

Lift devices, drawsheets, heel and elbow protectors, sleeves, and stockings.

Answer 307

Never drag a patient up in bed.

Answer 308

Specialty mattresses, integrated bed systems, mattress overlays consisting of air, gel, foam, and water.

Answer 309

To redistribute pressure and moisture to prevent bacterial growth on the skin.

Answer 310

Products specifically designed for that purpose; pillows may not be effective.

Answer 311

Avoid donut-type devices.

Answer 312

To prevent tissue damage from ischemia ## Footnote Ischemia refers to insufficient blood supply to tissues, which can lead to tissue damage and pressure injuries.

Answer 313

At least every 2 hours ## Footnote More frequent turning is required for patients with fragile skin or little subcutaneous tissue.

Answer 314

Every hour, with weight shifts every 15 minutes

Answer 315

Elevate the head of bed at a 30° angle or less; side-lying at a 30° angle ## Footnote This positioning helps avoid direct pressure on the trochanter.

Answer 316

* Characteristics of healthy skin * Appearance of skin with unrelieved pressure * Skin protection and injury prevention * Skin care and hygiene

Answer 317

* Rapid weight loss * Increased metabolic demands * Limited intake * Decreased serum albumin

Answer 318

30-35 kcal/kg/day

Answer 319

Soft diet for patients who are frail or missing teeth

Answer 320

* Tube feeding * Parenteral nutrition * Dietary referral as needed

Answer 321

* Monitor hydration status * Offer water when repositioning * Provide adequate calories and protein

Answer 322

[pressure-redistributing]

Answer 323

What is your typical activity level? ## Footnote Understanding the patient's activity level can help identify risk factors for skin issues.

Answer 324

Do you ever use a wheelchair or mobile device to get around? Do you require assistance to get out of bed or a chair? ## Footnote This assesses the patient's mobility and potential risk for skin breakdown.

Answer 325

Tell me about your usual diet. ## Footnote Nutrition plays a crucial role in skin health and wound healing.

Answer 326

How much liquid do you drink each day? ## Footnote Adequate hydration is essential for skin integrity.

Answer 327

Do you have any areas of numbness and tingling? ## Footnote Numbness and tingling can indicate neurological issues that affect skin health.

Answer 328

Have you had any recent changes in your skin? ## Footnote Identifying changes can help in early detection of potential skin problems.

Answer 329

Do you have any sores or open areas? If so, how long have you had the wound? ## Footnote Duration of a wound can indicate severity and need for intervention.

Answer 330

Have you ever had difficulty with wound healing? ## Footnote Previous healing difficulties can indicate underlying issues.

Answer 331

What kinds of healthcare problems have you been experiencing? ## Footnote Understanding broader health issues can inform skin and wound care.

Answer 332

What medications - prescribed, herbal, or over the counter - are you taking? ## Footnote Some medications can affect skin integrity or wound healing.

Answer 333

What is your typical hygiene routine? ## Footnote Hygiene practices can directly impact skin health.

Answer 334

Do you ever lose control of your bladder or bowels? ## Footnote Incontinence can lead to skin breakdown and wounds.

Answer 335

Do you smoke? ## Footnote Smoking can impair circulation and affect skin health.

Answer 336

How much time do you spend outdoors? ## Footnote Sun exposure and outdoor activity can affect skin conditions.

Answer 337

Do you have diabetes? If so, how often do you check your feet? How often do you see a podiatrist? What is your average blood sugar? ## Footnote Diabetes can significantly impact skin health and wound healing.

Answer 338

Localized area of intact skin with nonblanchable redness ## Footnote Nonblanchable redness does not become pale under applied light pressure.

Answer 339

Usually over a bony prominence ## Footnote It is important to monitor areas over bony prominences for pressure injuries.

Answer 340

Painful, firm, soft, warmer or cooler compared to adjacent tissue ## Footnote These sensations may vary based on the individual and the severity of the injury.

Answer 341

More than 30 minutes ## Footnote This prolonged discoloration is a key indicator of a Stage 1 Pressure Injury.

Answer 342

May not have visible blanching and color may differ from surrounding area ## Footnote This makes detection of Stage 1 Pressure Injuries more challenging in dark-skinned individuals.

Answer 343

False ## Footnote Stage 1 Pressure Injuries do not present with maroon or purple discoloration.

Answer 344

Involves partial-thickness loss of dermis and is open but shallow with a red-pink wound bed. ## Footnote It does not include slough (necrotic tissue) or bruising.

Answer 345

May be: * An intact or open/ruptured serum-filled blister * A shiny or dry shallow ulcer without slough or bruising ## Footnote The injury remains shallow and does not involve deeper tissue.

Answer 346

Do not mistake for: * Moisture-associated skin damage * Fungal infections ## Footnote These conditions can present similarly but are different from pressure injuries.

Answer 347

False. ## Footnote Stage 2 pressure injury specifically does not involve sloughing.

Answer 348

Red-pink. ## Footnote This color indicates healthy granulation tissue rather than necrotic tissue.

Answer 349

sloughing or bruising. ## Footnote This distinction is crucial for accurate diagnosis.

Answer 350

A deep crater with full-thickness skin loss and damage or necrosis of subcutaneous tissue. Adipose is visible. ## Footnote Full-thickness skin loss means that the injury extends through the epidermis and dermis into the subcutaneous tissue.

Answer 351

Extremely deep, especially in areas with significant adipose layers; may extend down to, but not through, underlying fascia. ## Footnote The depth can vary based on the location and amount of adipose tissue present.

Answer 352

Undermining of adjacent tissue may be present. ## Footnote Undermining refers to deeper-level damage under boggy superficial layers.

Answer 353

No, bone/tendon is not visible or directly palpable.

Answer 354

Involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures. ## Footnote Exposed bone/tendon is visible or directly palpable.

Answer 355

Slough or eschar (tan, black, or brown leathery necrotic tissue) may be present. ## Footnote Eschar refers to dead tissue that falls off from healthy skin.

Answer 356

The depth varies by location and can be shallow on areas like the bridge of the nose, ear, occiput, and malleolus due to lack of subcutaneous tissue. ## Footnote These areas are more prone to pressure injuries due to their anatomical structure.

Answer 357

* Ebole (rolled edges) * Undermining * Sinus tracts (blind tracts underneath the epidermis) ## Footnote These features indicate the severity and complexity of the injury.

Answer 358

Yes, it can extend into muscle and supporting structures (e.g., fascia, tendon, or joint capsule). ## Footnote This extension complicates the healing process and may require advanced treatment.

Answer 359

Often requires a full year to heal. ## Footnote Healing time can vary based on individual health factors and treatment approaches.

Answer 360

The site remains at risk for future injury because the scar tissue is not as strong as the original tissue. ## Footnote This highlights the importance of ongoing care and monitoring after healing.

Answer 361

An area of skin that is intact but persistently discolored

Answer 362

Purplish or deep red

Answer 363

Painful, boggy, or have a blister

Answer 364

Pain and temperature change

Answer 365

Damage of underlying soft tissue from pressure or shear

Answer 366

Findings can be subtle enough that often DTI is not recognized until after severe tissue damage has occurred

Answer 367

May heal or evolve further and become covered by thin eschar

Answer 368

Rapidly exposing additional layers of tissue

Answer 369

Discoloration might go undetected

Answer 370

Involves full-thickness skin loss ## Footnote The depth cannot be determined until slough or eschar is removed.

Answer 371

Slough or eschar ## Footnote Slough can be tan, yellow, gray, green, or brown; eschar can be tan, black, or brown.

Answer 372

Dry, adherent, and intact without erythema or fluctuance ## Footnote It serves as the body's natural cover.

Answer 373

False ## Footnote The depth cannot be assessed until the base of the wound is exposed.

Answer 374

slough and/or eschar

Answer 375

Location, Size, Appearance, Drainage, Patient Responses ## Footnote These are the key categories for wound assessment.

Answer 376

In anatomical terms, e.g., a midsternal incision extending from the manubrium to the xiphoid process ## Footnote This helps provide clarity in communication regarding the wound's position.

Answer 377

Length and width in centimeters, depth with a sterile cotton-tipped applicator ## Footnote Use photo documentation to indicate dimensions, especially for irregular borders.

Answer 378

Type of wound, color, condition of the wound bed, presence of necrosis, slough, eschar, and surrounding skin condition ## Footnote Detailed descriptions help in assessing healing and potential complications.

Answer 379

A beefy red, moist appearance ## Footnote This suggests that the wound is healing properly.

Answer 380

Discoloration, hematoma, additional injury, maceration, tunneling, crepitus, blistering, erythema ## Footnote These observations can indicate complications or the severity of the wound.

Answer 381

Color, consistency, amount, and odor ## Footnote Quantify drainage by weighing dressings before and after use.

Answer 382

Apply direct pressure and call the physician if bleeding continues after 5 minutes ## Footnote Immediate action is crucial in managing severe bleeding.

Answer 383

If last immunization was 10 years ago or longer, wound is contaminated and last shot was over 5 years ago, or if uncertain about immunization history ## Footnote Tetanus shots are important for preventing infection in wounds.

Answer 384

Additional observation and/or antibiotics ## Footnote Bite wounds are prone to infection and may need special attention.

Answer 385

Level of pain, with severe pain requiring comprehensive evaluation ## Footnote Pain assessment is critical for appropriate management of wounds.

Answer 386

Diabetes, malnutrition, immunocompromise, bleeding disorders ## Footnote Patients with these conditions require ongoing evaluation due to impaired healing.

Answer 387

Wounds that can be stabilized heal more rapidly than those affected by constant movement ## Footnote Location can also indicate the wound's etiology.

Answer 388

healing ## Footnote This appearance is a positive sign in wound assessment.

Answer 389

Determine if it is an acute or chronic wound

Answer 390

Closure, wound edges, tension, and stitch integrity

Answer 391

In a neutral position, measuring length, width, and depth in centimeters

Answer 392

A sterile cotton-tip applicator

Answer 393

To document baseline and wound healing

Answer 394

Separation in tissue type or plane at the wound edges

Answer 395

Using the face of a clock as a guide

Answer 396

Hematoma or additional injury

Answer 397

Excessive moisture from pooled drainage on intact skin

Answer 398

Gas trapped under the skin

Answer 399

Erythema, swelling, or other signs of irritation

Answer 400

Closed or rolled wound edges

Answer 401

Soft, stringy, and pale yellow or gray moist necrotic tissue

Answer 402

Dry necrotic tissue that appears thick, hard, and black or brown

Answer 403

maceration

Answer 404

The types of tissue and their amounts in the wound base ## Footnote Assessment of tissue types can indicate healing progress and necessary interventions.

Answer 405

Viable (living) tissue from nonviable tissue ## Footnote This distinction is crucial for appropriate wound management.

Answer 406

By percentages, e.g., '80% granulation tissue, 20% necrotic' ## Footnote This method provides a clear picture of the wound composition.

Answer 407

Evidence of healing ## Footnote Granulation tissue is a positive sign in wound healing.

Answer 408

A delay in healing ## Footnote These characteristics can signify complications in the healing process.

Answer 409

It will delay wound healing and should be removed ## Footnote The only exception is stable eschar on a heel that is not infected.

Answer 410

Whether exudate is present and its characteristics ## Footnote Key characteristics include amount, color, consistency, and odor.

Answer 411

None, light, moderate, or heavy ## Footnote Drainage amounts can vary by wound type.

Answer 412

Serous, serosanguineous, sanguineous, purulent, or seropurulent ## Footnote These terms help in assessing the nature of the wound fluid.

Answer 413

Clean the wound of all exudate or foreign material ## Footnote This ensures that the odor characteristics are accurately evaluated.

Answer 414

Fistula formation or bacterial contamination ## Footnote An example includes a previously odorless abdominal wound that begins to smell of bile or feces.

Answer 415

delay ## Footnote This highlights the importance of addressing necrotic tissue promptly.

Answer 416

False ## Footnote Venous stasis ulcers typically produce more drainage.

Answer 417

Wound Healing ## Footnote Wound healing is a critical aspect of nursing care, particularly in managing various types of wounds.

Answer 418

Interprofessional collaboration ## Footnote Collaboration among healthcare professionals leads to improved patient outcomes and a stronger healthcare system.

Answer 419

* Diabetic foot ulcers * Venous stasis ulcers * Pressure injury ## Footnote These wounds often require specialized care and input from various healthcare professionals.

Answer 420

* Trust * Effective communication * Role clarity * Mutual respect ## Footnote These traits foster a collaborative environment that enhances patient care.

Answer 421

Wound navigator ## Footnote The wound navigator acts as an advocate for patients and coordinates care among team members.

Answer 422

To advocate for patients and collaborate with healthcare professionals ## Footnote The navigator focuses on patient needs and ensures a comprehensive care plan.

Answer 423

A list of care/service providers ## Footnote This list includes names and contact information for appropriate resources, aiding patient access to care.

Answer 424

communication ## Footnote Effective communication is crucial for understanding roles and coordinating care.

Answer 425

True ## Footnote The model emphasizes care efforts based on patient needs and desires.

Answer 426

Various logistical and communication challenges ## Footnote Addressing these challenges is crucial for effective team functioning.

Answer 427

By enhancing communication and information sharing ## Footnote Technology can streamline processes and improve patient outcomes in wound care.

Answer 428

Soft, moist, devitalized (necrotic) tissue; may be white, yellow, tan; may be stringy, loose, or adherent to bed. ## Footnote Débride the wound.

Answer 429

Necrotic tissue; dry, thick, leathery; may be black, brown, or gray depending on moisture level. ## Footnote Débride the wound.

Answer 430

Pink to red moist tissue; made of new blood vessels, connective tissue, and fibroblasts; surface is granular or pebble-like. ## Footnote Cleanse, protect. Promote epithelialization (epithelial growth).

Answer 431

Absence of granulation tissue, but bed is pink, shiny, and smooth. ## Footnote Cleanse, protect. Promote growth of healthy tissue.

Answer 432

Regenerating epidermis; may appear pink or pearly white as it crosses the wound bed; may begin as a ring around the wound or from epithelial cells lining hair follicles. ## Footnote Cleanse, protect.

Answer 433

About pain or discomfort related to the wound or wound care.

Answer 434

Always take seriously the patient’s complaint of pain, especially if there is a sudden increase.

Answer 435

Pain is often an early symptom of infection.

Answer 436

Screen and assess the nutritional status of each patient admitted with a pressure injury and whenever there is a change in the patient’s condition.

Answer 437

If nutritional problems are present.

Answer 438

Sufficient calories.

Answer 439

Adding oral supplemental meals, or even enteral or parenteral nutrition.

Answer 440

The same assessments as for a treated wound, plus additional assessments to determine immediate treatment needs.

Answer 441

Bleeding, severe pain, numbness, or loss of movement below the wound.

Answer 442

Apply direct pressure to the site.

Answer 443

Call the provider immediately.

Answer 444

Severe pain, numbness, or loss of movement below the wound.

Answer 445

Wounds such as compound fractures, gunshot wounds, crush injuries, burns, punctures, foreign object injuries, and wounds contaminated with soil.

Answer 446

If the last immunization was 10 or more years ago, if the wound is contaminated and the last immunization was over 5 years ago, or if it is uncertain when the last immunization was received.

Answer 447

compound fractures, gunshot wounds, crush injuries, burns, punctures, foreign object injuries, wounds contaminated with soil.

Answer 448

History and physical assessment findings

Answer 449

* Protein levels * Complete blood count * Erythrocyte sedimentation rate * Glucose * Thyroid levels * Iron levels * Coagulation studies * Wound cultures

Answer 450

* Local or systemic signs of infection * Suddenly elevated glucose levels * Pain in a neuropathic extremity * Lack of healing after 2 weeks in a clean wound

Answer 451

* Swab * Aspiration * Tissue biopsy

Answer 452

When antibiotic-resistant bacteria is not suspected

Answer 453

Insertion of a needle into the tissue to aspirate tissue fluid

Answer 454

Inadvertent needle damage to tissue and underlying structures

Answer 455

Tissue biopsy

Answer 456

* Risk of sepsis * Causes pain * Disrupts the wound bed * May cause delayed healing

Answer 457

[tissue biopsy]

Answer 458

5,000–10,000/mm3

Answer 459

Potential infection

Answer 460

Delayed wound healing

Answer 461

Inflammatory reaction, phagocytosis of bacteria and debris, creation of antibodies

Answer 462

Serum protein: 6.0–8.0 g/dL; Serum albumin: 3.4–4.8 g/dL

Answer 463

Limited nutritional stores that delay wound healing or increase risk for pressure injury

Answer 464

Closely related but fluctuate slowly

Answer 465

Prealbumin level

Answer 466

A test that indicates whether red blood cells stick together, become heavier, and settle at the bottom of a laboratory tube when held vertically. ## Footnote ESR is used to assess the presence of inflammation or necrotic processes in the body.

Answer 467

0–15 mm/hr ## Footnote The ESR range varies with age.

Answer 468

0–20 mm/hr ## Footnote Normal ESR values can increase with age.

Answer 469

False ## Footnote An increased ESR indicates altered blood proteins due to inflammation or necrosis.

Answer 470

inflammatory ## Footnote The test reflects changes in blood proteins due to inflammation.

Answer 471

Activated Partial Thromboplastin Time

Answer 472

Equipment and reagents used

Answer 473

Greater than 70 seconds or less than 53 seconds

Answer 474

Excessive blood loss or ongoing bleeding in the wound bed

Answer 475

* Blood clot formation problems * Deep vein thrombosis * Pulmonary embolus * Stroke

Answer 476

Clotting time

Answer 477

Greater than 20 seconds (uncoagulated) or three times normal control (anticoagulated)

Answer 478

Anticoagulant medications, concurrent illness, trauma, reaction to transfusions

Answer 479

A standardized test to evaluate clotting times, considered the gold standard ## Footnote The INR is crucial for monitoring patients on anticoagulation therapy.

Answer 480

Less than 2.0 ## Footnote This indicates normal clotting function in patients not on anticoagulants.

Answer 481

2.0–3.0 ## Footnote This range is generally therapeutic for patients on anticoagulants.

Answer 482

True ## Footnote The INR helps assess the effectiveness of anticoagulation therapy.

Answer 483

To determine the types of bacteria present in the wound

Answer 484

By swab, aspiration, or tissue biopsy

Answer 485

Colonization with bacteria

Answer 486

No growth of pathogens

Answer 487

It is used to examine tissue samples for the presence of pathogens or abnormalities. ## Footnote Tissue biopsies are crucial in diagnosing diseases, including infections and cancers.

Answer 488

No growth of pathogens. ## Footnote A negative result suggests that there are no infectious agents present in the sampled tissue.

Answer 489

Exceeds 100,000 organisms per gram of tissue. ## Footnote This threshold helps in determining whether a wound requires treatment for infection.

Answer 490

The presence of beta-hemolytic streptococci in any number indicates infection. ## Footnote This specific type of bacteria is pathogenic even in low quantities.

Answer 491

The RN ## Footnote Ongoing evaluation of a wound also requires the RN.

Answer 492

Inspection of the skin for evidence of skin breakdown ## Footnote UAP should notify the RN of redness, tissue warmth, or drainage.

Answer 493

Provide times for turning and specific positioning instructions ## Footnote A turning chart at the bedside can be helpful.

Answer 494

Tissue damage from ischemia ## Footnote This is crucial for preventing pressure injury.

Answer 495

Risk for Impaired Skin Integrity ## Footnote This applies to patients with risk factors like immobility and incontinence.

Answer 496

* Immobility * Incontinence * Extremes of age * Impaired circulation * Impaired sensation * Undernutrition * Emaciation ## Footnote Use a risk assessment tool to identify these patients.

Answer 497

[Norton or Braden scale] ## Footnote These tools help assess the risk for skin breakdown.

Answer 498

Ability to respond meaningfully to pressure-related discomfort

Answer 499

Degree to which skin is exposed to moisture

Answer 500

Degree of physical activity

Answer 501

Ability to change and control body position

Answer 502

Usual food intake pattern

Answer 503

Factors contributing to skin breakdown due to movement

Answer 504

Unresponsive to painful stimuli due to diminished level of consciousness or sedation

Answer 505

Skin is kept moist almost constantly by perspiration, urine, etc.

Answer 506

Confined to bed

Answer 507

Does not make even slight changes in body or extremity position without assistance

Answer 508

Never eats a complete meal and rarely eats more than ½ of any food offered

Answer 509

Responds only to painful stimuli, cannot communicate discomfort except by moaning

Answer 510

Skin is often, but not always moist, requiring linen change at least once a shift

Answer 511

Ability to walk severely limited or non-existent, must be assisted into chair or wheelchair

Answer 512

Rarely eats a complete meal, generally eats only about ½ of any food offered

Answer 513

Potential Problem

Answer 514

Responds to verbal commands but cannot always communicate discomfort

Answer 515

Skin is occasionally moist, requiring an extra linen change approximately once a day

Answer 516

Walks occasionally during the day, but for very short distances

Answer 517

Eats over half of most meals, takes a total of 4 servings of protein per day

Answer 518

Responds to verbal commands and has no sensory deficit limiting ability to feel pain

Answer 519

Skin is usually dry, linen only requires changing at routine intervals

Answer 520

Walks outside room at least twice a day and inside room at least once every two hours during waking hours

Answer 521

Makes major and frequent changes in position without assistance

Answer 522

Eats most of every meal, never refuses a meal, and usually eats a total of 4 or more servings of protein

Answer 523

To assess patients' risk for pressure ulcers ## Footnote The Norton Scale evaluates physical condition, mental condition, activity, mobility, and incontinence.

Answer 524

Scores of 14 or less ## Footnote Scores below 12 indicate a very high risk for developing pressure ulcers.

Answer 525

* Physical Condition * Mental Condition * Activity * Mobility * Incontinence ## Footnote Each criterion is scored, and the total score determines the risk level.

Answer 526

20 ## Footnote This score represents the best possible outcome for patient risk assessment.

Answer 527

True ## Footnote Scores below 12 suggest a significant risk for patients.

Answer 528

[five criteria] ## Footnote These criteria include physical condition, mental condition, activity, mobility, and incontinence.

Answer 529

A score of 2 ## Footnote This indicates a significant concern for the patient's overall health status.

Answer 530

A score of 3 ## Footnote This score reflects a patient's reduced engagement or responsiveness.

Answer 531

2 ## Footnote This indicates limited mobility and increased risk for pressure ulcers.

Answer 532

A score of 1 ## Footnote This status significantly increases the risk for pressure ulcers.

Answer 533

5 ## Footnote This score indicates a very high risk for pressure ulcers.

Answer 534

Impaired Skin Integrity ## Footnote Appropriate for patients with superficial wounds or stage 1 or 2 pressure injury.

Answer 535

Impaired Tissue Integrity ## Footnote Used for patients with deep wounds or stage 3 or 4 pressure injury.

Answer 536

Risk for Impaired Tissue Integrity ## Footnote Example: A patient with a stage 1 pressure injury at risk for progression due to age, nutritional state, and presence of another wound.

Answer 537

Risk for Infection ## Footnote Also consider if the patient is undernourished or immobile.

Answer 538

Pain ## Footnote This includes discomfort from treatments required to heal the wound.

Answer 539

Disturbed Body Image ## Footnote Important to consider even if the patient is expected to make a complete recovery or if disfigurement is expected.

Answer 540

* Bedrest Care * Infection Protection * Pressure Injury Prevention * Pressure Management * Skin Surveillance * Nutrition Management * Positioning * Wound Care * Wound Irrigation * Specific nursing activities directed at maintaining skin integrity or healing wounds.

Answer 541

Preventing and treating pressure injury and other chronic wounds, providing wound care, and applying heat and cold therapies.

Answer 542

* Dietitians * Infection control specialists * Wound specialists

Answer 543

All pressure must be taken off the area to prevent trauma to healing tissues.

Answer 544

The appropriate dressing and a special shoe made for patients with neuropathy.

Answer 545

Compression garments such as elastic hose, stockings, or multilayer compression wraps.

Answer 546

They provide continuous pressure to the veins, improving venous return and helping the ulcer to heal.

Answer 547

Ensure the limb is not increasing in size due to edema.

Answer 548

Lower extremity arterial disease.

Answer 549

To remove exudate, slough, foreign materials, and microorganisms from the wound ## Footnote This promotes healthy tissue healing.

Answer 550

Initially and with each dressing change ## Footnote This ensures ongoing cleanliness and promotes healing.

Answer 551

Gently pat the surface with gauze soaked with saline or other prescribed wound cleanser ## Footnote Care should be taken not to disrupt granulation tissue.

Answer 552

Isotonic, easy to sterilize, inexpensive, available, non-irritating, and non-damaging to tissue ## Footnote It should not cause bleeding.

Answer 553

* Dakin solution * Acetic acid * Hydrogen peroxide * Povidone-iodine * Chlorhexidine * Alcohol ## Footnote These have been historically used to cleanse various types of wounds.

Answer 554

They can damage granulating tissue ## Footnote This can hinder the healing process.

Answer 555

* New wounds * Wounds that will not heal * Wounds where bacterial burden is more harmful than the solution ## Footnote This approach minimizes potential harm to healing tissue.

Answer 556

Isotonic and safe for injured or healing tissue ## Footnote It cleanses most wounds effectively if used in sufficient amounts.

Answer 557

It should be used within 24 hours to avoid bacterial growth ## Footnote This ensures the solution remains safe for use.

Answer 558

Clean, contain no additives, less expensive than normal saline ## Footnote Both are hypotonic and can cause fluid shifts to damaged cells.

Answer 559

Water toxicity to an open wound ## Footnote This is due to the hypotonic nature of sterile water.

Answer 560

Yes, it is as effective as saline ## Footnote The decision to use tap water should consider the nature of the wound and the patient's condition.

Answer 561

Nature and complexity of the wound, patient's general condition, presence of comorbid conditions, immunological status ## Footnote Examples of comorbid conditions include diabetes.

Answer 562

Purified water ## Footnote This reduces the risk of microbial contamination from biofilm.

Answer 563

A coating of bacteria that adheres to a surface ## Footnote Biofilms form in hospital water delivery systems and impede wound healing.

Answer 564

Reduces the effectiveness of fibroblasts and antimicrobials ## Footnote This can lead to delayed healing and increased risk of infection.

Answer 565

Liquid or foam skin cleansers that are pH balanced ## Footnote These are not for use inside wounds.

Answer 566

To cleanse wounds by flushing debris and bacteria on the surface ## Footnote This includes hydrating the site and improving visual inspection of the wound.

Answer 567

* Facilitates progression from the inflammatory to the proliferative phase of healing * Reduces infection by preventing premature surface healing ## Footnote This is particularly important over an infected area of a wound.

Answer 568

Normal saline ## Footnote Bacterial growth in saline may occur as soon as 24 hours after opening the saline bottle.

Answer 569

* Topical cleansers * Antiseptics * Antibiotics * Antifungals * Anesthetics * Analgesics ## Footnote These solutions serve to clean wounds, prevent or treat infection, and manage pain.

Answer 570

* Nonhemolytic * Nontoxic to healing tissue * Transparent ## Footnote Other characteristics include being inexpensive and warmed to room temperature.

Answer 571

False ## Footnote Cytotoxic solutions may impair wound healing.

Answer 572

It should be warmed to room temperature to prevent hypothermia.

Answer 573

Transparent

Answer 574

Improves wound healing from the inside tissue layers to the skin surface.

Answer 575

Irrigation ## Footnote A larger, sterile, disposable syringe designed to minimize hand slippage.

Answer 576

Increases the risk of aspirating drainage and disrupting healing granulation tissue ## Footnote Bulb syringes can cause complications during wound care.

Answer 577

* Whirlpool agitators * Pulsed lavages ## Footnote These systems are used for delivering irrigation solutions effectively.

Answer 578

An uninterrupted stream of irrigation solution to the wound’s surface ## Footnote This method is used for consistent wound care.

Answer 579

The intermittent delivery of irrigation solution ## Footnote This technique allows for more controlled irrigation.

Answer 580

4 psi to 15 psi ## Footnote This range is effective for removing debris without causing harm.

Answer 581

35-mL syringe attached to a 19-gauge angiocatheter ## Footnote This setup helps effectively manage wound care.

Answer 582

* Driving bacteria into tissues * Causing mechanical damage to the wound * Dislodging healing granulation tissue ## Footnote High-pressure irrigation can lead to serious complications.

Answer 583

35 psi to 70 psi ## Footnote These systems can cause complications in wound healing.

Answer 584

True ## Footnote They can drive bacteria deeper into the wound compartment.

Answer 585

50 to 100 mL ## Footnote This volume may vary based on the level of contamination and type of wound.

Answer 586

More irrigation volume is needed ## Footnote This ensures thorough cleansing of the wound.

Answer 587

More irrigation volume is needed ## Footnote Chemical burns can be particularly severe and require extensive flushing.

Answer 588

Gowns, masks, and goggles ## Footnote These items help protect the healthcare provider from potential exposure.

Answer 589

A plastic shield ## Footnote This is particularly useful for IV sites and other open areas.

Answer 590

For acute surgical wounds, wounds recently undergoing sharp débridement, or as prescribed by the provider ## Footnote Sterile technique minimizes infection risk.

Answer 591

Clean technique ## Footnote This is sufficient for many types of wounds that are not severely contaminated.

Answer 592

To allow fluid and exudate to exit and prevent excessive pressure from building up in the tissues.

Answer 593

During a surgical procedure.

Answer 594

A flexible, flat latex tube placed in the wound bed, usually not sutured into place.

Answer 595

With a clip or pin at the insertion site to prevent slipping.

Answer 596

Drains attached to a collection device for fluid removal.

Answer 597

The device is compressed to create suction and facilitate the removal of drainage.

Answer 598

Connect the drain to wall suction as prescribed by the provider.

Answer 599

Using the drain’s position on a clock face with the patient’s head at the 12 o’clock position.

Answer 600

The amount and character of the drainage.

Answer 601

Check the drain line for kinks and notify the provider if the problem persists.

Answer 602

Empty the apparatus at a designated volume as it fills.

Answer 603

Penrose Flowers in a vase can be moved

Answer 604

Suction pressure decreases.

Answer 605

To ensure consistent care by each caregiver.

Answer 606

The amount and character of the drainage.

Answer 607

The removal of devitalized tissue or foreign material from a wound. ## Footnote It also involves removing senescent cells from the wound bed and edges.

Answer 608

To stimulate wound healing and prepare the wound bed for advanced therapies or biological agents. ## Footnote This includes the removal of exudate and infective material.

Answer 609

Eschar. ## Footnote This is critical to avoid further complications in the healing process.

Answer 610

A type of eschar that should be left alone during débridement. ## Footnote It indicates a stable condition that does not require intervention.

Answer 611

In cases where the patient is critically unstable or has a grave prognosis. ## Footnote This consideration is crucial for patient safety and care.

Answer 612

Five types. ## Footnote These types include sharp (surgical), mechanical, enzymatic, autolytic, and biotherapy (maggot) therapy.

Answer 613

A type of débridement performed surgically. ## Footnote It involves the use of surgical instruments to remove tissue.

Answer 614

A type of débridement that uses physical force to remove tissue. ## Footnote This can include methods like irrigation or wet-to-dry dressings.

Answer 615

A type of débridement that uses enzymes to break down necrotic tissue. ## Footnote This method is often applied topically.

Answer 616

A type of débridement that relies on the body’s own mechanisms to remove dead tissue. ## Footnote This process is facilitated by moisture-retentive dressings.

Answer 617

A type of débridement that uses live maggots to consume necrotic tissue. ## Footnote This method is effective in promoting healing in certain types of wounds.

Answer 618

The use of a sterile, sharp instrument, such as scalpel or scissors, to remove devitalized tissue.

Answer 619

Provides an immediate improvement of the wound bed and preserves granulation tissue.

Answer 620

A physician, nurse, or physical therapist with specialized training.

Answer 621

In the operating room.

Answer 622

A bone biopsy.

Answer 623

Osteomyelitis, extension of the infection into the bone.

Answer 624

[sterile, sharp instrument]

Answer 625

Mechanical débridement may be performed via lavage, wet-to-damp dressings, or hydrotherapy.

Answer 626

Coarse gauze moistened with normal saline packed into the wound, allowed to dry, and removed several times a day.

Answer 627

It causes pain and provides only nonselective débridement, removing both debris and healing granulation tissue.

Answer 628

Medicate the patient beforehand with opioid analgesics.

Answer 629

It aids in removal and decreases pain but may eliminate the débriding action.

Answer 630

A vigorous form of nonselective débridement using a whirlpool for wounds with a large amount of nonviable tissue.

Answer 631

Usually performed in the physical therapy department once or twice per day for 5 to 15 minutes.

Answer 632

Do not expose the wound directly to the water jets.

Answer 633

* Increased risk for periwound maceration * Contamination by waterborne infections * Cross-contamination * Vasodilation, increasing edema and congestion * Increased risk for burns in persons with diabetic neuropathies

Answer 634

To remove nonviable tissue from wounds.

Answer 635

Enzymatic débridement uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound. ## Footnote It involves cleaning the wound with normal saline, applying a thin layer of cream, and covering with a moisture-retaining dressing.

Answer 636

Once or twice daily, depending on the product. ## Footnote It is important to apply the product only to devitalized tissue.

Answer 637

Autolytic débridement (autolysis) is the use of an occlusive, moisture-retaining dressing and the body’s own enzymes and defense mechanisms to break down necrotic tissue. ## Footnote This process is slower but better tolerated than other techniques.

Answer 638

Every 72 hours, or sooner if drainage breakthrough occurs. ## Footnote The wound should be cleansed before applying a new dressing.

Answer 639

Tan. ## Footnote Observing the fluid is part of the monitoring process.

Answer 640

Signs of infection, such as an increase in pain or a foul odor. ## Footnote Regular observation is crucial for timely intervention.

Answer 641

infection or immunosuppression.

Answer 642

The use of medical-grade larvae of the greenbottle fly to dissolve dead and infected tissue from wounds ## Footnote The larvae secrete enzymes that break down dead tissue while neutralizing on healthy tissue.

Answer 643

They secrete enzymes that break down dead tissue ## Footnote The enzymes are neutralized upon contact with normal tissue, protecting healthy areas.

Answer 644

They digest bacteria from the wound ## Footnote This helps reduce infection and promotes healing.

Answer 645

Containing the larvae within the dressing can be problematic ## Footnote Larvae are typically changed every 48 to 72 hours.

Answer 646

Disposed of as biohazardous medical waste ## Footnote This is important for safety and infection control.

Answer 647

It can be emotionally disturbing to both patients and nurses ## Footnote Discussing this with the patient is essential.

Answer 648

Maintains the right amount of moisture for cells to flourish ## Footnote This is crucial for healing.

Answer 649

Function as a barrier to water vapor loss ## Footnote They help prevent dehydration of body cells.

Answer 650

Purpose, duration, change frequency, and removal ease ## Footnote These factors help ensure effective treatment.

Answer 651

* Prevent drying of the wound bed * Absorb drainage * Keep surrounding tissue dry and intact * Protect from contamination and infection * Aid in hemostasis * Débride the wound * Eliminate dead space * Prevent heat loss * Splint the wound site * Provide comfort to the patient * Control odor * Minimize scarring ## Footnote Each of these goals contributes to effective wound management.

Answer 652

Dressings placed in the wound bed that physically touch the wound

Answer 653

A dressing that covers or holds a primary dressing in place

Answer 654

Yes, many dressings can touch the wound bed and secure themselves with adhesive

Answer 655

Each wound must be treated and dressed individually based on patient history and assessment

Answer 656

No, each wound must be treated individually

Answer 657

No, the newest dressing is not necessarily the best for the wound being treated

Answer 658

The needs of the wound and not the manufacturer's brand name

Answer 659

Ongoing reassessment of the dressing choice

Answer 660

To adapt as the wound evolves

Answer 661

[shapes and forms]

Answer 662

Highly absorptive layers of fibers such as cellulose, cotton, or rayon ## Footnote May or may not have an adhesive border.

Answer 663

Partial- or full-thickness wounds ## Footnote Used as a primary or secondary dressing to manage drainage.

Answer 664

Moderate to large amounts of drainage

Answer 665

To pack undermining wounds or if the wound is not draining ## Footnote Can dry out the wound bed and damage tissue.

Answer 666

Brown seaweed and kelp

Answer 667

Pad or rope form

Answer 668

Very high absorbency (20–40 times their weight)

Answer 669

A moist environment and facilitate autolytic débridement

Answer 670

Wounds that have depth, tracts, tunneling, or undermining

Answer 671

A nonadhesive gel is created ## Footnote Must irrigate this gel from the wound before placing the next dressing.

Answer 672

Allergy to antibiotic components, seaweed, or kelp

Answer 673

Antibiotic and antifungal

Answer 674

Ointments, impregnated gauzes, pads, gels, foams, hydrocolloids, and alginates

Answer 675

Silver and iodine

Answer 676

Reduce exudate and prevent infection by reducing bacteria in the wound, promote collagen deposition

Answer 677

Allergy to silver or iodine

Answer 678

Partial- or full-thickness wounds, malodorous wounds with little to large amounts of drainage, highly contaminated or infected wounds

Answer 679

Bovine (cow) or porcine (pig) sources

Answer 680

Sheets, pads, powders, and gels

Answer 681

Partial- and full-thickness and contaminated or infected wounds

Answer 682

Absorb exudate

Answer 683

Promote a moist wound bed for healing

Answer 684

Wounds to produce collagen fibers and granulation tissue

Answer 685

Ensure the patient has no religious practices that would forbid this use

Answer 686

Minimal to large

Answer 687

Easy to apply and remove

Answer 688

Semipermeable hydrophilic foam that forms an impermeable barrier over the wound

Answer 689

Wafers, rolls, and pillows

Answer 690

Film coverings; can be adhesive or nonadhesive

Answer 691

Wounds with moderate to heavy exudates

Answer 692

Thermal insulation

Answer 693

A moist environment

Answer 694

No, they do not stick to the wound bed

Answer 695

Yes, they can be used under compression

Answer 696

Friable periwound skin

Answer 697

They can be shaped around body contours

Answer 698

Alginates or films

Answer 699

No, do not use with wounds that have tunneling or tracts

Answer 700

No, not recommended

Answer 701

May macerate periwound skin

Answer 702

Opaque, with inability to see wound bed for assessment

Answer 703

High probability of bacterial invasion

Answer 704

moderate to heavy

Answer 705

Gauze ## Footnote Gauze is a common choice for various wound care needs.

Answer 706

Cleansing and Protection ## Footnote Gauze dressings help to clean wounds and protect them from external contaminants.

Answer 707

Labor intensive ## Footnote Gauze dressings require careful management and frequent changes.

Answer 708

Woven and nonwoven fibers of cotton, rayon, polyester, or a combination ## Footnote These materials contribute to the absorbency and flexibility of the dressing.

Answer 709

Packing large wounds, cavities, or tracts, deep or dirty wounds, or heavily draining wounds ## Footnote Their versatility makes them suitable for various wound types.

Answer 710

Amorphous hydrogels, saline, or medications ## Footnote Combining gauze with these substances can enhance wound healing.

Answer 711

Sterile or nonsterile ## Footnote This allows for flexibility based on the clinical situation.

Answer 712

Does not ensure a moist wound environment ## Footnote Gauze can allow for fluid evaporation, which is not ideal for healing.

Answer 713

It can damage new, regenerated cells with gauze removal ## Footnote This can impede the healing process.

Answer 714

Gauze must be fluffed ## Footnote Proper application is crucial to prevent complications.

Answer 715

Amount of fluid saturation of the gauze ## Footnote Monitoring saturation helps maintain effective wound care.

Answer 716

Hypothermic (cold) wound ## Footnote This condition can impair cell growth for healing.

Answer 717

Wafers, pastes, or powders that contain hydrophilic particles

Answer 718

They form a gel that keeps the wound moist

Answer 719

They provide a protective layer against friction, caustic agents, and bacteria and reduce pain

Answer 720

Wounds with minimal exudates, such as partial-thickness wounds and stage 2 pressure injuries

Answer 721

They mold to the shape of the body, making them useful for difficult areas

Answer 722

To create an even surface on which to place the ostomy appliance

Answer 723

For wounds surrounded by friable or sensitive skin and for infected wounds

Answer 724

It can produce an odor that might be confused with a malodorous wound

Answer 725

Clean the wound bed first

Answer 726

These wounds must be packed and allowed to drain

Answer 727

May facilitate the growth of anaerobic bacteria

Answer 728

Sheets, granules, or gels with a high water content, creating a jelly-like consistency that does not adhere to the wound bed.

Answer 729

Enhance epithelialization to promote a moist environment.

Answer 730

Rehydrate the wound bed.

Answer 731

Promote autolysis.

Answer 732

Soft, cooling texture.

Answer 733

Have limited absorptive capabilities (not practical for wounds with significant exudate).

Answer 734

Require a secondary dressing.

Answer 735

Soften slough or eschar.

Answer 736

Easily macerate periwound skin due to high moisture content.

Answer 737

Liquid transparent copolymer ## Footnote Skin sealants are specifically designed to provide a protective barrier on the skin.

Answer 738

Petrolatum, dimethicone, zinc-based products ## Footnote These components help protect the skin from exudate, moisture, urine, and feces.

Answer 739

Wiped or sprayed on skin ## Footnote They can be applied to protect the skin from wound exudate and moisture.

Answer 740

To protect skin from exudate, moisture, urine, and feces ## Footnote They serve as a protective layer for vulnerable skin.

Answer 741

With each dressing change ## Footnote They are simple and fast to use, ensuring ongoing protection.

Answer 742

Moisture, friction, skin stripping from adhesives ## Footnote They provide a barrier against various forms of skin injury.

Answer 743

False ## Footnote Ointments can impair the adhesion of wound dressings or tapes.

Answer 744

moisture and mechanical and chemical skin injury ## Footnote This protective barrier is essential for maintaining skin integrity.

Answer 745

Clear and semipermeable materials ## Footnote Used in wound dressing to provide a moist environment.

Answer 746

A moist environment ## Footnote This helps in the healing process of wounds.

Answer 747

Tissues will become macerated ## Footnote This is due to excessive moisture retention.

Answer 748

Occlusive with oxygen permeability ## Footnote This allows for gas exchange while protecting the wound.

Answer 749

Autolysis ## Footnote This is the body's own process of breaking down dead tissue.

Answer 750

To dress IV sites ## Footnote They help prevent contamination and maintain a sterile environment.

Answer 751

External bacterial contamination ## Footnote This is crucial for maintaining the integrity of the wound.

Answer 752

Allow wound assessment without removing or disturbing the dressing ## Footnote This minimizes trauma to the wound during evaluations.

Answer 753

Yes, without inhibiting movement ## Footnote This makes them versatile for various body areas.

Answer 754

Do not use them on friable skin ## Footnote They adhere strongly and can cause further damage.

Answer 755

Wound size, location, amount of drainage, frequency of dressing changes, patient’s activity level, type of dressings used

Answer 756

Provides stability, tough, durable, leaves residue, can cause trauma to skin upon removal

Answer 757

Commercial adhesive removers

Answer 758

Allergic skin reactions

Answer 759

Nonallergenic tape, paper tape

Answer 760

Ask about history of tape allergies or irritation

Answer 761

Place strips of tape at the ends and space them evenly over the dressing

Answer 762

Porous tapes, thin hydrocolloids, low-adhesion foam dressings, skin sealants

Answer 763

Decrease pulling and irritation of skin around a wound

Answer 764

Adhesive part to skin at ends and spaced intervals, lace cloth ties to secure dressing

Answer 765

Whenever they become soiled

Answer 766

Keep in place until they begin to loosen

Answer 767

Infection control measures recommended by the CDC for all patients

Answer 768

CDC Tier Two: Contact Level Precautions in addition to Standard Precautions

Answer 769

To secure a dressing that requires frequent changing

Answer 770

Place them in a private room or with a patient with the same organism

Answer 771

Wash your hands frequently and thoroughly with soap and warm water

Answer 772

When caring for the patient with a wound

Answer 773

Change gloves and wash hands before applying a clean dressing

Answer 774

The least contaminated wound

Answer 775

Sterile technique with sterile instruments

Answer 776

Signs of sepsis (e.g., fever, tachycardia, hypotension, altered consciousness)

Answer 777

Only specially trained providers

Answer 778

Sterile dressings

Answer 779

Clean dressings, unless the patient is immunocompromised

Answer 780

In biohazard waste receptacles

Answer 781

Discard them

Answer 782

In a clean and dry area

Answer 783

Do not share supplies

Answer 784

Access only the number needed for the dressing change

Answer 785

Touching the supply with gloves that have come in contact with the wound

Answer 786

To hold a dressing in place, apply pressure to a wound, and support and immobilize an injured area ## Footnote This promotes healing and comfort.

Answer 787

The purpose of the application and the part being bandaged ## Footnote This ensures appropriate use and effectiveness.

Answer 788

To keep a wound closed or to immobilize a body part ## Footnote This aids in the healing process.

Answer 789

Cloth or elasticized material ## Footnote They may fasten with straps, pins, or Velcro.

Answer 790

To support the upper extremities ## Footnote Commercial slings are commonly available.

Answer 791

To secure dressings or pads in the perineal area ## Footnote It helps maintain cleanliness and protection.

Answer 792

To provide support to the abdomen, especially after an incision or open wound ## Footnote It decreases the risk of dehiscence.

Answer 793

dehiscence

Answer 794

False ## Footnote Binders are typically used on large areas of the body.

Answer 795

A cloth, gauze, or elastic covering that is wrapped in place

Answer 796

1.5 to 7.5 cm (0.5 to 3 in.)

Answer 797

On small body parts, such as a finger

Answer 798

As slings to immobilize an upper extremity or to hold large abdominal dressings in place

Answer 799

It readily conforms to the shape of the body

Answer 800

Medications or plaster of Paris

Answer 801

To apply pressure and give support

Answer 802

Ace bandages

Answer 803

A continuous strip of material that you unroll as you apply it to a body part

Answer 804

15°C to 45°C (59°F to 113°F)

Answer 805

Area being treated, nature of the injury, duration of treatment, patient age, physical condition, and condition of the skin

Answer 806

They adapt to the new temperature and the person notices it less

Answer 807

Changing the temperature after adaptation occurs

Answer 808

The very young and the very old

Answer 809

Increased risk for injury due to inability to perceive temperature changes

Answer 810

Highly vascular areas such as fingers, hand, face, and perineum

Answer 811

Decreases the patient’s tolerance of the treatment

Answer 812

Intact skin tolerates heat and cold therapy better

Answer 813

To relieve stiffness and discomfort associated with musculoskeletal problems and for patients with wounds.

Answer 814

Vasodilatation may cause a drop in blood pressure and a feeling of faintness.

Answer 815

Through vasodilatation, increased capillary permeability, and reduced blood viscosity.

Answer 816

It brings oxygen and white blood cells (WBCs) to the wound and aids in the healing process.

Answer 817

Moist heat and dry heat.

Answer 818

washcloths, gauze compresses, soaks, and baths.

Answer 819

Do not microwave moistened towels to warm them.

Answer 820

It causes unequal heat distribution and may cause burns to the patient.

Answer 821

To apply moist heat when there are open areas on the skin.

Answer 822

To immerse the affected area, cleanse a wound, and remove encrusted material.

Answer 823

A type of bath that soaks the patient’s perineal area.

Answer 824

Electric heating pads, disposable hot packs, or hot water bags.

Answer 825

Patients should place the heating pad over the body area and never lie on it.

Answer 826

A device that circulates water in the interior of the pad to create a constant temperature.

Answer 827

Providing a constant temperature ## Footnote However, there is a high risk of burns associated with their use.

Answer 828

Dry heat application ## Footnote Aquapads circulate water in the interior to create a constant temperature.

Answer 829

Disposable hot packs and hot water bags or bottles ## Footnote Hot water bags are common for home use but pose a burn risk in healthcare settings.

Answer 830

Vasoconstriction and decreased capillary permeability ## Footnote Additional effects include local anesthesia, reduced cell metabolism, increased blood viscosity, and decreased muscle tension.

Answer 831

* Prevent or limit edema * Reduce inflammation and pain * Reduce oxygen requirements * Help control bleeding * Treat fevers * Treat musculoskeletal injuries * Prevent swelling after surgery ## Footnote Examples include using an ice bag on the perineum after childbirth or an ice collar after tonsillectomy.

Answer 832

* Elevated blood pressure * Shivering * Tissue damage ## Footnote Elevated blood pressure occurs due to vasoconstriction; shivering is a normal response to prolonged cold; tissue damage can result from impaired circulation.

Answer 833

Vasoconstriction

Answer 834

False ## Footnote Hot water bags are common for in-home use but are not recommended in healthcare settings due to burn risks.

Brainscape's Knowledge GenomeTM

Exam 2 module 3 part 5 Flashcards

Skin and Wound Healing Ch 32

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