SKIN INTEGRITY

Question 1

Many medications increase sensitivity to sunlight
and can predispose one to severe sunburns. Some of the most common medications that cause this damage are certain antibiotics

Answer 1

(e.g.,
tetracycline and doxycycline),

Question 2

chemotherapy drugs for cancer

Answer 2

(e.g.,
methotrexate)

Question 3

TYPES OF WOUNDS

are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary
tracts are not entered. These are primarily closed wounds

Answer 3

• Clean wound

Question 4

TYPES OF WOUNDS

are surgical wounds in which the
respiratory, gastrointestinal, genital, or urinary tract has been entered. Such wounds show no evidence of infection.

Answer 4

Clean-contaminated wounds

Question 5

TYPES OF WOUNDS

s include open, fresh, accidental wounds and
surgical wounds involving a major break in sterile technique or a
large amount of spillage from the gastrointestinal tract. These wounds show evidence of inflammation

Answer 5

Contaminated wounds

Question 6

TYPES OF WOUNDS

include wounds containing dead tissue
and wounds with evidence of a clinical infection, such as purulent
drainage.

Answer 6

Dirty or infected wounds

Question 7

consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in
combination with movement

Answer 7

Pressure ulcers

Question 8

Pressure ulcers were previously called

Answer 8

decubitus ulcers, pressure sores, or bedsores.

Question 9

One of the
national patient safety goals for long-term care settings is prevention of
health care–associated pressure ulcers

Answer 9

(The Joint Commission, 2013).

Question 9

they proposed objective is to reduce the
rate of pressure ulcer–related hospitalizations among older adults

Answer 9

. A Healthy People 2020

Question 10

Types of Wounds

Sharp instrument (e.g., knife or scalpel

Open wound; deep or shallow; once the edges
have been sealed together as a part of treatment
or healing, this becomes a closed wound.

Answer 10

Incision

Question 11

Types of Wounds

Blow from a blunt instrument

Closed wound, skin appears ecchymotic
(bruised) because of damaged blood vessels.

Answer 11

Contusion

Question 12

Types of Wounds

Surface scrape, either unintentional (e.g., scraped knee from a fall)
or intentional (e.g., dermal abrasion to remove pockmarks)

Open wound involving the skin

Answer 12

Abrasion

Question 13

Types of Wounds

Penetration of the skin and often the underlying tissues by a sharp
instrument, either intentional or unintentional

Open wound

Answer 13

Puncture

Question 14

Types of Wounds

Tissues torn apart, often from accidents (e.g., with machinery)

Open wound; edges are often jagged

Answer 14

Laceration

Question 15

Types of Wounds

Penetration of the skin and the underlying tissues, usually
unintentional (e.g., from a bullet or metal fragments)

Open wound

Answer 15

Penetrating
wound

Question 16

Classifying Wounds by Depth

confined to the skin, that is, the dermis and
epidermis; heal by regeneration

Answer 16

• Partial thickness:

Question 17

Classifying Wounds by Depth

involving the dermis, epidermis, subcutaneous
tissue, and possibly muscle and bone; require connective
tissue repair

Answer 17

• Full thickness:

Question 18

After the skin has been compressed, it appears pale, as if the
blood had been squeezed out of it. When pressure is relieved, the skin takes on a bright red flush, called

Answer 18

reactive hyperemia

Question 19

Pressure ulcers are due to localized

Answer 19

ischemia

Question 20

is a force acting parallel to the skin surface.

Answer 20

Friction

Question 21

The flush
is due to ____, a process in which extra blood floods to the
area to compensate for the preceding period of impeded blood flow

Answer 21

vasodilation

Question 22

refers to a reduction in the amount and control of movement a person has.

Answer 22

Immobility

Question 22

is a combination of friction and pressure

Answer 22

Shearing force

Question 23

(abnormally low protein content in the blood)

Answer 23

Hypoproteinemia

Question 24

(the presence of excess interstitial fluid) makes skin more prone to injury by decreasing its elasticity, resilience, and vitality

Answer 24

Edema

Question 25

(tissue softened by prolonged wetting or soaking)

Answer 25

maceration

Question 26

(area of loss of the superficial layers of the skin; also known as denuded area).

Answer 26

excoriation

Question 27

what tool for Predicting Pressure Sore Risk consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Answer 27

The Braden Scale

Question 28

braden scale A total of___ points is possible and an adult who scores below ___ points is considered at risk

Answer 28

23, 18

Question 29

what tools should be used when the client first enters the health care agency and whenever the client’s condition changes

Answer 29

The Braden and Norton tools

Question 30

Healing is a quality of living tissue; it is also referred to as ___ (renewal) of tissues.

Answer 30

regeneration

Question 31

Norton’s Pressure Area Risk Assessment Scoring System. It includes the categories of general physical condition, mental state, activity, mobility, and incontinence. A category of medications is added by some users, resulting in a possible score of ___ Scores of ____ should be viewed as indicators, not predictors, of risk.

Answer 31

24., 15 or 16

Question 32

Types of Wound Healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring

Answer 32

Primary intention healing

Question 33

Types of Wound Healing A wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated, heals by

Answer 33

secondary intention healing

Question 34

Types of Wound Healing Wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by

Answer 34

tertiary intention.

Question 35

tertiary intention. This is also called

Answer 35

delayed primary intention.

Question 36

Phases of Wound Healing begins immediately after injury and lasts 3 to 6 days

Answer 36

INFLAMMATORY PHASE

Question 37

Phases of Wound Healing the second phase in healing, extends from day 3 or 4 to about day 21 postinjury. Fibroblasts (connective tissue cells), which migrate into the wound starting about 24 hours after injury, begin to synthesize collagen

Answer 37

PROLIFERATIVE PHAS

Question 38

Phases of Wound Healing begins on about day 21 and can extend 1 or 2 years after the injury. Fibroblasts continue to synthesize collagen. The collagen fibers themselves, which were initially laid in a haphazard fashion, reorganize into a more orderly structure. During maturation, the wound is remodeled and contracted.

Answer 38

MATURATION PHASE

Question 39

INFLAMMATORY PHASE Two major processes occur during this phase:

Answer 39

hemostasis and phagocytosis

Question 40

(the cessation of bleeding) results from vasoconstriction of the larger blood vessels in the affected area, retraction (drawing back) of injured blood vessels, the deposition of fibrin (connective tissue), and the formation of blood clots in the area

Answer 40

Hemostasis

Question 41

. These macrophages engulf microorganisms and cellular debris by a process known as

Answer 41

phagocytosis.

Question 42

is a whitish protein substance that adds tensile strength to the wound

Answer 42

Collagen

Question 42

Initially, wounds healing by secondary intention seep blood-tinged ____ drainage.

Answer 42

(serosanguineous)

Question 43

In some individuals, particularly dark-skinned individuals, an abnormal amount of collagen is laid down. This can result in a

Answer 43

hypertrophic scar, or keloid

Question 44

One method of documenting the progress of healing in pressure ulcers is to use the

Answer 44

Pressure Ulcer Scale for Healing (PUSH) tool

Question 45

is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.

Answer 45

Exudate

Question 46

The three major types of exudate are

Answer 46

serous, purulent, and sanguineous.

Question 47

Types of Wound Exudate consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum. It looks watery and has few cells. An example is the fluid in a blister from a burn.

Answer 47

serous exudate

Question 48

Types of Wound Exudate is thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria

Answer 48

purulent exudate

Question 49

Types of Wound Exudate consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. This type of exudate is frequently seen in open wounds

Answer 49

sanguineous exudate

Question 50

The process of pus formation is referred to as

Answer 50

suppuration

Question 51

a localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise)

Answer 51

a hematoma,

Question 52

is the partial or total rupturing of a sutured wound. _____ usually involves an abdominal wound in which the layers below the skin also separate

Answer 52

Dehiscence

Question 53

is the protrusion of the internal viscera through an incision

Answer 53

Evisceration

Question 54

Diagnosing : vulnerable to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear

Answer 54

* Risk for Pressure Ulcer

Question 55

Diagnosing vulnerable to alteration in epidermis and/or dermis which may compromise health.

Answer 55

* Risk for Impaired Skin Integrity

Question 56

Diagnosing altered epidermis and/or dermis

Answer 56

* Impaired Skin Integrity:

Question 57

Diagnosing damage to mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligamen

Answer 57

* Impaired Tissue Integrity

Question 58

Diagnosing if the skin impairment is severe, the client is immunosuppressed, or the wound is caused by trauma

Answer 58

Risk for Infection

Question 59

Diagnosing related to nerve involvement within the tissue impairment or as a consequence of procedures used to treat the wound.

Answer 59

Acute Pain

Question 60

Mechanical Devices for Reducing Pressure on Body Parts Polyvinyl, silicone, or Silastic pads filled with a gelatinous substance similar to fat.

Answer 60

Gel flotation pads

Question 61

Mechanical Devices for Reducing Pressure on Body Parts Supports positioning and offloads bone on bone contact.

Answer 61

Pillows and wedges

Question 62

Mechanical Devices for Reducing Pressure on Body Parts Can raise or “float” a body part (e.g., heels) off the surface. Prevent shearing and limit pressure on heel area

Answer 62

Heel protectors

Question 63

Mechanical Devices for Reducing Pressure on Body Parts Polyurethane foam mattress distributes weight over bony areas evenly. Foam molds to the body

Answer 63

Memory foam mattress/chair pad

Question 64

Mechanical Devices for Reducing Pressure on Body Parts Composed of a number of cells in which the pressure alternately increases and decreases; uses a pump.

Answer 64

Alternating pressure mattress

Question 65

Mechanical Devices for Reducing Pressure on Body Parts Support surface filled with water. Water temperature can be controlled.

Answer 65

Water bed

Question 66

Mechanical Devices for Reducing Pressure on Body Parts Consists of many air-filled cushions divided into four or five sections. Separate controls permit each section to be inflated to a different level of firmness; thus pressure can be reduced on bony prominences but increased under other body areas for support

Answer 66

Static low-air-loss (LAL) bed

Question 67

Mechanical Devices for Reducing Pressure on Body Parts Like the static LAL, but in addition gently pulsates or rotates from side to side, thus stimulating capillary blood flow and facilitating movement of pulmonary secretions.

Answer 67

Active or second-generation LAL bed

Question 68

Mechanical Devices for Reducing Pressure on Body Parts Forced temperature-controlled air is circulated around millions of tiny silicone-coated beads, producing a fluid-like movement. Provides uniform support to body contours.

Answer 68

Air-fluidized (AF) bed (static high-air-loss bed)

Question 69

Types of Dressings are often applied to wounds including ulcerated or burned skin areas.

Answer 69

Hydrocolloid Dressings

Question 70

Types of Dressings are frequently used over pressure ulcers

Answer 70

Hydrocolloid Dressings

Question 71

Types of Dressings The nurse tapes the dressing over the wound, ensuring that the dressing covers the entire wound and does not become dislodged.

Answer 71

Securing Dressings

Question 72

has been a common source of dry heat used in the home. It is convenient and relatively inexpensive. H

Answer 72

Hot Water Bag

Question 73

(also referred to as a K-pad) is constructed with tubes containing water. The pad is attached by tubing to an electrically powered control unit that has an opening for water and a temperature gauge

Answer 73

Aquathermia Pad

Question 74

provide a constant, even heat, are lightweight, and can be molded to a body part.

Answer 74

Electric Heating Pads

Question 75

is a moist gauze dressing applied to a wound or injury

Answer 75

compress

Question 76

or hip bath, is used to soak a client’s perineal or rectal area.

Answer 76

A sitz bath,