Skin Integrity

Question 1

Trauma or wounds that occur during therapy.

Answer 1

Intentional

Question 2

Wounds that are accidental.

Answer 2

Unintentional

Question 3

Are uninfected wounds in which there is minimal inflammation and the gastrointestinal, genital, and urinary tracts are not entered.

Answer 3

Clean wounds

Question 4

Are surigical wounds in which the gastrointestinal, genital, or unirary tract has been entered but shows no evidence of infection.

Answer 4

Clean-contaminated wounds

Question 5

Include open, accidental, and surigcal wounds involving a major break in sterile technique. Wounds show inflammation.

Answer 5

Contaminated wounds

Question 6

Include wounds with evidence of a clinical infection.

Answer 6

Dirty or infected wounds

Question 7

Are confined to the skin, that is, the dermis and epidermis.

Answer 7

Partial thickness wounds

Question 8

Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.

Answer 8

Full thickness wounds

Question 9

Consist of injury to the skin or underlying tissues, usually over a bony prominence, as a result of force.

Answer 9

Pressure Injuries

Question 10

A deficiency in the blood supply to the tissue

Answer 10

Ischemia

Question 11

Is a force acting parallel to the skin surface.

Answer 11

Friction

Question 12

Is a combination of friction and pressure.

Answer 12

Shearing force

Question 13

Refers to a reduction in the amount and control of movement an individual has.

Answer 13

Immobility

Question 14

Occurs when the tissue surfaces haven been closed and there is minimal or no tissue lost.

Answer 14

Primary intention healing

Question 15

Wounds that are extensive and involves considerable tissue loss, and in which the edge cannot or should not be approximated.

Answer 15

Secondary intention healing

Question 16

Allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures.

Answer 16

Tertiary intention healing

Question 17

Begins immediately after injury and lasts 3 to 6 days.

Answer 17

Inflammatory Phase

Question 18

Extends from day 3 to 4 to about day 21 postinjury.

Answer 18

Proliferative Phase

Question 19

Begins on about day 21 and can extend 1 or 2 years after the injury.

Answer 19

Maturation Phase

Question 20

Is a material such as fluid and cells which has escaped from blood vessels during inflammatory process.

Answer 20

Exudate

Question 21

Consists chiefly of serum. It looks watery and has few cells.

Answer 21

Serous exudate