Exam 3 - integumentary system and wounds

Question 1

pallor

Answer 1

• loss of color, in black skin tones can change to a grey color
• look particularly in the mucous membranes
• indication: anemia, shock, lack of blood flow

Question 2

cyanosis

Answer 2

• bluish discoloration, in brown skin tones can turn yellow-brown or grey
• nail beds, lips, mucosa
• indication: hypoxia, impaired venous return

Question 3

jaundice

Answer 3

• yellow discoloration
• sclera, skin, mucous membranes
• indication: liver dysfunction (RBC destruction)

Question 4

erythema

Answer 4

• redness, difficult to see in darker skin tones, palpate skin as well to look for warmth and texture changes
• face, skin, pressure prone areas
• indication: inflammation, vasodilation, sun exposure, elevated body temperature

Question 5

shear

Answer 5

• sliding movement of skin and subcutaneous tissue when muscle and bone are not moving

Question 6

friction

Answer 6

• two surfaces moving across one another

Question 7

moisture

Answer 7

• duration and amount of moisture determine risk

Question 8

pressure injuries

Answer 8

• impaired skin integrity related to unrelieved, prolonged pressure

Question 9

factors involved in pressure injury development

Answer 9

• pressure intensity
• pressure duration
• tissue tolerance

Question 10

blanchable

Answer 10

• turns lighter when pressed and then erythema returns
• there is hope with this
• may overcome ischemia

Question 11

non-blanchable

Answer 11

• does not turn lighter in color when pressed; remains erythematous
• deep tissue damage

Question 12

stage 1 pressure injury

Answer 12

• intact skin with a localized area of nonblanchable erythema
• may appear differently in darkly pigmented skin

Question 13

stage 2 pressure injury

Answer 13

• partial-thickness skin loss with exposed dermis

Question 14

stage 3 pressure injury

Answer 14

• full-thickness loss of skin, in which adipose tissue is visible in the ulcer and granulation tissue and epibole are often present

Question 15

stage 4 pressure injury

Answer 15

• full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage and bone in the ulcer

Question 16

deep tissue injury

Answer 16

• persistent non-blanch able deep red, maroon, or purple discoloration
• cannot tell what layers are involved

Question 17

unstageable pressure injury

Answer 17

• obscured by infection or dying skin (slough/eschar), cannot determine involvement

Question 18

incontinence related skin damage

Answer 18

• prolonged exposure to urine or stool

Question 19

intertriginous skin damage

Answer 19

• inflammatory dermatitis related to moist skin on rubbing against each other

Question 20

periwound/peristomal skin damage

Answer 20

• associated with wound or stomas and enzyme breakdown associated with the exudate

Question 21

wound

Answer 21

• disruption of the integrity and function of the tissues
• pressure injuries can be wounds

Question 22

acute wounds

Answer 22

• proceeds through normal/timely repair process
• results in return to normal/sustained function and anatomical integrity
• example: trauma/surgical incision

Question 23

chronic wounds

Answer 23

• wound that fails to proceed through normal healing process
• does not return to normal function/anatomical integrity
• example: pressure ulcer, vascular insufficiency wound

Question 24

labs associated with skin and wound healing

Answer 24

serum albumin and pre-albumin

Question 25

nutrition involved with skin and wound healing

Answer 25

• deficiencies result in delayed healing
• protein, vitamin A & C, zinc, copper are critical for healing
• adequate caloric intake necessary

Question 26

tissue perfusion

Answer 26

• ability to perfuse tissues with oxygenated blood crucial to wound healing
• diabetes/peripheral vascular disease are at risk for poor tissue perfusion

Question 27

infection

Answer 27

• prolongs the inflammation and delays healing
• purulent drainage, changes in color/volume/redness around the tissue, fever or pain
• low WBC b/c of inability to fight infection

Question 28

age wound healing

Answer 28

• affects all aspects of wound healing
• delayed inflammatory responses, delayed collagen synthesis, and slower epithelization

Question 29

wound drainage

Answer 29

• result of the healing process: can be normal or abnormal
• accumulates during the inflammatory and proliferative phases of healing

Question 30

serous exudate

Answer 30

• portion of blood (serum) that is watery and clear or slightly yellow in appearance

Question 31

sanguineous exudate

Answer 31

• serum and red blood cells, thick and appears reddish
• brighter indicates active bleeding
• darker indicates older bleeding

Question 32

serosanguinous exudate

Answer 32

• contains serum and blood, watery, looks pale/pink

Question 33

purulent exudate

Answer 33

• result of infection
• thick, contains WBCs, tissue debris, and bacteria
• yellow, tan, green, brown

Question 34

wet to dry wound dressing

Answer 34

• used to mechanically debride a wound until granulation tissue starts to form

Question 35

hydrocolloid wound dressing

Answer 35

• occlusive dressing that swells in the presence of exudate
• example: duoderm

Question 36

hydrogel wound dressing

Answer 36

• mostly water, gels after contact with exudate, promotes autolytic debridement, rehydrates and fills dead space
• not for wounds that are draining a lot
• for infected, deep wounds or necrotic tissue

Question 37

alginates wound dressing

Answer 37

• nonadherent dressing that conform to wound shape and absorb exudate

Question 38

collagen wound dressing

Answer 38

• powders
• pastes
• granules
• gels

Question 39

wound vacs

Answer 39

• use of foam strips into the wound bed with occlusive dressing - creates negative pressure to occur once the tubing is connected
• helps with tissue generation, decrease swelling, and enhance healing in moist, protective environment

Question 40

hemorrhage wound problem

Answer 40

• greatest risk 24-48 hours after surgery
• clot dislodgment, slipped suture, or blood vessel damage
• can be an emergency
• apply pressure dressing, notify provider, monitor vital signs

Question 41

dehiscence

Answer 41

• partial or total rupture (separation) of a sutured wound, usually with a separation of underlying skin layers

Question 42

evisceration

Answer 42

• a dehiscence that involves that protrusion of visceral organs through wound opening