integumentary/ wound care

Question 1

What are the names of the 3 burn zones?

Answer 1

Zone of Coagulation
Zone of Stasis
Zone of Hyperemia

Question 2

What is the zone of Zone of Coagulation?

Answer 2

The Zone of Coagulation is the area where irreversible cell death occurs.

Question 3

What is the Zone of Stasis?

Answer 3

The area that many die without specialized care in 24-48 hours.

Question 4

What is the Zone of Hyperemia?

Answer 4

The area of minimal cell injury; these cells should recover.

Question 5

This the percentages of skin coverage as noted by the rule of 9’s.

Answer 5

Head Neck- 9%
Anterior Trunk- 18%
Posterior Trunk-18%
Each Arm- 9%
Each Leg - 18%
Perineum- 1 %

Question 6

What is termed a Critical Burn?

Answer 6

3rd Degree - 10%
&
2nd Degree - 30% or more
(complications are common)

Question 7

What is termed a Moderate Burn?

Answer 7

3rd Degree -

Question 8

What is termed a Minor Burn?

Answer 8

3rd Degree -

Question 9

What are common complications with burns?

Answer 9

Infection (leading cause of death is from gangrene)
Shock Pulmonary Complicaitons
Metabolic Complications
Cardiac/ Circulatory Complications

Question 10

What are the characteristics of a Superficial (1st degree) Burn?

Answer 10

Damage to epidermis only. Pink/ red no blistering (dry surface). Minimal edema. Tenderness/ delayed pain.

Question 11

What are the characteristics of a Superficial Partial- Thickness Burn?

Answer 11

Epidermis and upper layers of dermis are damaged. Bright pink/ red appearance. Blisters, moist surface, weeping, moderate edema, painful, sensitive to touch, temperature changes.

Question 12

How long does it take for a Superficial Burn to heal?

Answer 12

Healing is spontaneous within 3-7 days (1 week), no scaring

Question 13

How long does it take for a Superficial Partial-Thickness Burn to heal?

Answer 13

Healing is spontaneous within 7-21 days (1-3 weeks), minimal scarring/discoloration

Question 14

How long does it take for a Superficial Full Thickness Burn to heal?

Answer 14

Removal of eschar and skin grafting is necessary for healing to occur. Risk of infection increased. Hypertrophic scarring/ contracture will occur without preventative measures

Question 15

What are the characteristics of a Superficial Full Thickness (3rd degree) Burn?

Answer 15

Complete destruction of the epidermis, dermis, and subcutaneous tissues, may extend to muscle. Grey, charred or black appearance, poor distal circulation, parchmentlike dry leathery surface. Little pain nerve destroyed

Question 16

What are the characteristics of a Sub-dermal (4th degree) Burn?

Answer 16

Complete destruction of the epidermis, dermis, and subcutaneous tissue with muscle damage. Charred appearance.Destruction of vascular system may lead to necrosis

Question 17

How long does it take for a Sub-dermal (4th degree) Burn to heal?

Answer 17

Skin grafting required, scarring will occur. Extensive surgeries needed and amputation may be necessary.

Question 18

Pressure ulcer stage 1

Answer 18

Non-blanchable erythema of intact skin. May include changes in skin temperature, tissue consistency, or sensation

Question 19

Pressure ulcer stage 2

Answer 19

Partial-thickness skin loss: involves epidermis and/or dermis.Ulcer is superficial. Presents clinically as an abrasion, blister, or shallow crater.

Question 20

Pressure ulcer stage 3

Answer 20

Full-thickness skin loss: involves damage to or necrosis of subcutaneous tissue. May extend down to but not through, underlying fascia. Presents clinically as a deep crater.

Question 21

Pressure ulcer stage 4

Answer 21

Full thickness skin loss: involves extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may be present.

Question 22

Key points of arterial ulcers.

Answer 22

Pulses poor or absent
intermittent claudication -> pain at rest
thin shiny atrophic skin, loss of hair on the foot and toes,
nails thickend

Question 23

Key points of Diabetic ulcer.

Answer 23

Usually appear where arterial ulcers appear or where neuropathy appears.
not painful
pulses are present or diminished
Ankle jerk may be negative

Question 24

Key points of Venus Ulcer

Answer 24

Pulses are normal
no pain to aching pain
normal temp
marked edema
stasis dermatitis present