Exam 6 - Skin

Question 0

Blanching

Answer 0

To loose color

Question 1

Collagen

Answer 1

A protein substance that adds strength to a healing wound.

Question 2

Tissue ischemia

Answer 2

In adequate blood supply to tissue

Question 3

Tissue hypoxia

Answer 3

An oxygen deficiency to tissue.

Question 4

Induration

Answer 4

An area of hardened tissue.

Question 5

Normal reactive hyperemia

Answer 5

Skin flushes bright red when pressure to area is relieved extra blood rushes to area to compensate for ischemic period.

Question 6

Abnormal reactive hyperemia

Answer 6

When redness does not disappear quickly tissue damage has occurred.

Question 7

Eschar

Answer 7

Black leathery covering comprised of necrotic tissue and plasma protein

Question 8

Debridement

Answer 8

Removal of devitilized tissue allows would to heal and removes the medium for bacterial growth.

Question 9

Most common sites where pressure ulcers occur

Answer 9

Over bony prominences

Question 10

Primary intention

Answer 10

Minimal tissue loss, approximated edges

Question 11

Secondary intention

Answer 11

Extensive tissue loss edges not approximated. Heal from inner layer to outer layer by granulation.

Question 12

Tertiary intention

Answer 12

Delayed primary closure , initially heal 2nd intention , then suturing

Question 13

Serous

Answer 13

Serum “straw” colored watery in consistency

Question 14

Sanguineous

Answer 14

“Bloody” see with deep wounds or in highly vascular areas. Bright red = fresh bleeding : darker red = older bleeding

Question 15

Serosanguineous

Answer 15

Combination of bloody/serous drainage: commonly seen in new wounds “light pink”

Question 16

Purulent

Answer 16

Thick malodorous , pus, “yellow” in color, filled with WBCs, bacteria, and cellular debris : “infected” wounds.

Question 17

Purosanaguinous

Answer 17

Pus that is bloody/red tinged. Indicates small vessels in wound have ruptured.

Question 18

Evisceration

Answer 18

Total separation of layers of wound with internal viscera protruding through the incision rare but surgical emergency. Cover with sterile dressing soaked with NS

Question 19

Fistula

Answer 19

Abnormal passage connecting 2 body cavities most common sites is GI and GU tracts.

Question 20

Pressure ulcer wound assessment.

Answer 20

Location
Size
Appearance
Drainage.

Question 21

Pressure ulcer

Stage 1

Answer 21

Intact skin with non-blanching redness of a localized area usually over a bony prominence
Darkly pigmented skin may not have visible blanching its color may differ from surrounding area

Question 22

Pressure ulcer

Stage 2

Answer 22

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound without slough
May also present as an intact or ruptured serum-filled blister.

Question 23

Pressure ulcer

Stage 3

Answer 23

Full thickness tissue loss. Subcutaneous fat may be visible but bone tendon or muscle are not exposed.
Slough may be presented but does not obscure the depth. Of tissue loss
May include undermining and tunneling

Question 24

Pressure ulcer

Stage 4

Answer 24

Full thickness tissue loss with exposed bone , tendon, or muscle
Slough or eschar may be present on some parts of the wound bed
Often included undermining and tunneling.