SKIN INTEG & WOUND CARE

Question 1

What is Skin?

Answer 1

Largest Organ of the Body 1/6 of TBW, Synthesize Vita D, Protects, Sensory Organ

Question 2

Skin is Affected By?

Answer 2

Genetics, Age, Meds, Chronic Illness, Nutrition

Question 3

2 Principal Layers of the Skin?

Answer 3

Epidermis and Dermis

Question 4

Types of Wounds

Answer 4

Open, Close, Ulcer

Question 5

Open Wounds

Answer 5

Abrasion, Laceration, Puncture, Avulsions

Question 6

Abrasion is?

Answer 6

Skin rubbed on a rough surface with little to no bleeding

Question 7

Laceration is?

Answer 7

Jagged cut caused by sharp objects with extensive bleeding that needs stitches and heavy cleaning

Question 8

Puncture is?

Answer 8

Hole wound caused by objects such as gunshot and usually need tetanus or antibiotic shot

Question 9

Avulsion is?

Answer 9

Partial or complete tear of the skin caused by explosions or accidents

Question 10

Closed Wounds

Answer 10

Contusion, Blisters, Seroma, Hematoma, Crush Injury

Question 11

Contusion is?

Answer 11

Medical term for bruise with black to blue color caused of BV breakdown

Question 12

Blister is?

Answer 12

Bubble pops with fluid build up of clear water (serum)

Question 13

Seroma is?

Answer 13

Clear fluid build up near an incision surgical site

Question 14

Hematoma is?

Answer 14

Pool of clotted blood caused by BV breakdowns because of injury or trauma

Question 15

Crush injury is?

Answer 15

Prolonged compression of torso or limbs

Question 16

Ulcer wounds

Answer 16

Pressure, Venous, Arterial, Neuropathic

Question 17

Pressure ulcer is also known as?

Answer 17

Decubitus Ulcer, Pressure Sore, Bed Sore

Question 18

What is Ischemia?

Answer 18

Decreased blood supply to tissues

Question 19

What is Reactive Hyperemia?

Answer 19

Red Flush in localized site of wound

Question 20

What is Vasodilation?

Answer 20

Extra blood delivery to the impeded site of blood flow

Question 21

How does ulcer affect cellular metabolism?

Answer 21

Impedes blood flow causing ischemia

Question 22

Factors of pressure ulcer

Answer 22

Friction /Shearing, Poor Nutri, Incontinence (Maceration, Excoriation), Moisture, Activity, Immobility, Decreased LOC, Excessive Body Heat, Poor Lifting technique, incorrect pos

Question 23

What is LOC?

Answer 23

Level of Consciousness

Question 24

What is Maceration?

Answer 24

Too moist site making tissues soft

Question 25

What is Excoriation

Answer 25

Loss of Layers of the Skin

Question 26

Common sites of pressure ulcer of the back?

Answer 26

Heels, Tailbone, elbow, shoulder, back of the head

Question 27

Common site of pressure ulcer of the sides?

Answer 27

Ankle, Hips, knees, shoulder, ears

Question 28

Common site of pressure ulcer sitting?

Answer 28

Shoulder blade, buttocks, heels, ball of foot

Question 29

What is Stage 1 Pressure Ulcer?

Answer 29

Intact Skin, Non blanchable redness, pain, firm, warm/cool

Question 30

Stage 1 treatment?

Answer 30

Offload pressure, transparent film dressing, hydrocolloid dressing, moisture barrier

Question 31

What is Stage 2 Pressure Ulcer?

Answer 31

Partial Thickness loss of skin, superficial present/abrasion, bleeding, higher scarring, higher susceptibility

Question 32

Stage 2 treatment?

Answer 32

Hydrocolloid dressing, Absorptive dressing, Draining wound, Hydrogel Healing Wound

Question 33

What is Stage 3 Pressure Ulcer?

Answer 33

Full thickness loss of skin, deep crater

Question 34

Stage 3 treatment?

Answer 34

Draining: Absorptive Dressing, Neuropathic: Debridement, Granulation: Hydrogel Healing wound

Question 35

What is Stage 4 Pressure Ulcer?

Answer 35

Visible bone or palpable, full thickness loss of skin

Question 36

What is unstageable wound?

Answer 36

True depth is not determined due to slough or eschar

Question 37

Slough color?

Answer 37

Tan, Yellowish, Stringy

Question 38

Eschar Color?

Answer 38

Brown, Black

Question 39

Deep tissue injury?

Answer 39

Starts inside showing maroon or purple color above the localized site

Question 40

Risk assessment tools for pressure ulcer?

Answer 40

Norton Scale, Gosnell Scale, Braden Scale

Question 41

Braden scale subscales are?

Answer 41

Sensory percep, moisture, activity, mobility, nutrition, friction/shearing

Question 42

What is Primary Intention?

Answer 42

little to no loss of skin tissues, approximated

Question 43

What is Secondary Intention?

Answer 43

Excessive skin tissue loss, edges cannot be approximated, bleeding, higher scarring and susceptibility

Question 44

What is Tertiary Intention?

Answer 44

Also known as delayed primary intention, 3-5 days opened and closed by staples, sutures

Question 45

Phases of wound healing?

Answer 45

Inflammatory, Proliferative, Maturation

Question 46

Inflammatory phase?

Answer 46

3-6 days after injury, hemostasis, phagocytosis happens

Question 47

What is Hemostasis?

Answer 47

Bleeding is stopped

Question 48

What is Phagocytosis?

Answer 48

Defense is build up

Question 49

What is Proliferative phase?

Answer 49

3-21st day post injury, collagen synthesize, granulation of tissue occurs

Question 50

What is Maturation phase?

Answer 50

21st day to 2 years, collagen organize, remodeling, scarring present, keloid too

Question 51

What is Kelloid?

Answer 51

Hypertrophic scarring caused by collagen build up

Question 52

What is Hemorrhage?

Answer 52

Massive bleeding

Question 53

What is Infection?

Answer 53

Contaminated wound site during healing

Question 54

What is Dehiscence with possible evisceration?

Answer 54

Rupture of suture wound with protruding viscera

Question 55

What is Serous Exudate?

Answer 55

Serum build up with few watery cell

Question 56

What is Purulent exudate?

Answer 56

Puss filled build up

Question 57

What is Sanguineous exudate?

Answer 57

High number of RBC build up

Question 58

What is Serosanguineous exudate?

Answer 58

Blood clear build up

Question 59

What is Purosanguineous exudate?

Answer 59

Puss and blood build up