Exam II - Skin Integrity and Wound Care

Question 1

Slough

Answer 1

Soft, moist, devitalized tissue that may be yellow, tan, or green and either loose or firmly adherent

Question 2

Eschar

Answer 2

Eschar is typically tan, brown, or black, and may be crusty

Question 3

Interiginous Dermatitis (ITD)

Answer 3

Inflammation of skin where two surfaces rub such as groin, beneath breasts, and underarm area.

Question 4

Tissue Ischemia

Answer 4

Decreased blood flow to tissues

Question 5

Reactive hyperemia

Answer 5

A redness of the skin resulting from dilation of the superficial capillaries.

Question 6

Blanchable hyperemia

Answer 6

A type of erythema that becomes white when a finger is pressed down on it

Question 7

Nonblanchable hyperemia

Answer 7

A redness that persists after palpation and indicates tissue damage.

Question 8

Shear

Answer 8

The force exerted against the skin while the skin remains stationary and the bony structures move

Question 9

Friction

Answer 9

Surface damage caused by the skin rubbing against another surface that often results in an abrasion

Question 10

Primary intention

Answer 10

The skin edges approximate, or close together, and the risk for infection is minimal.

Question 11

Laceration

Answer 11

A wound involving loss of tissue that may heal by secondary intention

Question 12

Secondary Intention

Answer 12

The skin edges cannot come together because of the extensive tissue loss, and healing occurs gradually.

Question 13

Granulation tissue

Answer 13

Red, moist tissue consisting of blood vessels and connective tissue. Covers the wound base of a wound healing by secondary intention.

Question 14

Tertiary Intention

Answer 14

Or delayed primary closure. Wound heals with a layer of granulation tissue at the edges and base, and several days after initial wounding the health care provider brings the wound edges together with sutures or adhesive closures.

Question 15

Hemostasis

Answer 15

Cessation of bleeding by vasoconstriction and coagulation. Usually occurs within several minutes.

Question 16

Hematoma

Answer 16

A localized collection of blood under the tissue, often appearing as a blueish swelling or mass.

Question 17

Dehiscence

Answer 17

The partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly.

Question 18

Evisceration

Answer 18

Occurs when wound layers separate below the fascial layer and visceral organs protrude through the wound opening.

Question 19

Induration

Answer 19

Hardening of tissue caused by edema or inflammaiton

Question 20

Abrasion

Answer 20

Loss of the dermis

Question 21

Ecchymosis

Answer 21

Brusing or skin discoloration

Question 22

Maceration

Answer 22

Softening of the skin caused by moisture

Question 23

Debride

Answer 23

To remove necrotic tissue

Question 24

Binders

Answer 24

Are dressings made of large pieces of material to fit a specific body part

Question 25

Compress

Answer 25

A piece of gauze dressing moistened in a prescribed warmed solution

Question 26

Stiz bath

Answer 26

A bath in which only the pelvic area is immersed in warm fluid

Question 27

Examples of items used to perform heat therapy

Answer 27

Warm moist compresses, Sitz bath, Commercial hot packs, Aquathermia (water flow pad), Dry heat, hot water bottles, Electric heating pads,

Question 28

Examples of items used to perform cold therapy

Answer 28

Cold moist compresses, Cold soaks, ice bag or collar, Commercial cold packs