Skin Integrity

Question 0

Skin

Answer 0

Synthesizes vitamin D, it’s a protective organ, barrier

Question 1

Epidermis

Answer 1

Top layer of skin

Question 2

Dermis

Answer 2

Inner layer of skin

Question 3

Pressure ulcers

Answer 3

Have many names. It is the injury to skin and possibly underlining of the skin, usually over a bony prominence

Question 4

Causes of pressure ulcers

Answer 4

Shearing, friction, pressure, pressure intensity, pressure duration and how much the tissue can handle

Question 5

Impaired sensory perception

Answer 5

Patients can’t feel, usually diabetic, stroke or paralyzed victims

Question 6

Shear

Answer 6

Skin and tissue moves while the muscle and bone stay stationary

Question 7

Moisture

Answer 7

Reduces skin resistant and barriers. (Sweat, urine etc)

Question 8

Friction

Answer 8

Sliding or dragging skin across another area

Question 9

Classification of ulcers

Answer 9

Stage 1 (I)
Stage 2 (II)
Stage 3 (III)
Stage 4 (IV)

Question 10

Stage 1 (I) pressure ulcer

Answer 10

Intact skin with nonblanchable and redness

Question 11

Stage 2 (II)

Answer 11

Partial thickness skin loss involving epidermis, dermis or both. Redness looks like its on fire

Question 12

Stage 3 (III)

Answer 12

Full thickness tissue loss with visible fat exposed

Question 13

Stage 4 (IV)

Answer 13

Full thickness tissue loss with exposed bone, muscle, or tendon. By this point the skin feels like a wet juicy sponge. This is where the tissues and cells are drying or have died

Question 14

Norton scale Braden scale

Answer 14

Scales used to determine the stages of ulcers

Question 15

Factors influencing pressure ulcer formation

Answer 15

Nutrition, tissue perfusion, infection, age, and psychosocial impact of wounds

Question 16

Assessment of pressure ulcers

Answer 16

Look at all of the skin, presence of ulcers and if they are red or blanchable, if there were or are existing wounds

Question 17

Treatment of ulcers

Answer 17

Topical skin care, skin barriers, positioning (turn every 2 hours), support surfaces (use pillows, pressure reducing mattresses that decrease the amount of pressure exerted on a bony prominence)