Skin Integrity

Question 1

Stage one pressure injuries

Answer 1

Intact non blistered skin with nonblanchable erythema or persistent redness

Question 2

Stage 3 pressure injury

Answer 2

Full thickness wound that extends into subcutaneous tissue but DO NOT extend through fascia to muscle bone or connective tissue
May be undermining or tunneling present

Question 3

Undermining

Answer 3

Area of tissue loss present under intact skin, usually along the edges of the wound

Question 4

Tunnel

Answer 4

Narrow passageway extending outward from the edge of a wound

Question 5

Stage 2 pressure injury

Answer 5

Partial thickness wound that involves the upper dermis and dermis but does not extend below the level of the dermis
Shallow and superficial with pink wound bed
Intact or ruptured blisters that are the result of pressure

Question 6

Stage 4 pressure injury

Answer 6

For thickness wound involves exposure of muscles, bone, connective tissues such as tendons or Cartilage

Question 7

Unstageable pressure injury

Answer 7

For thickness when in which the amount of necrotic tissue or eschar in the room bed makes it impossible to assess the depth of the wound

Question 8

Deep tissue injury

Answer 8

Area of intact skin that is purple or maroon or a blood filled blister

Question 9

Keloids

Answer 9

Scars that grow larger than normal and have a smooth robbery appearance

Question 10

Why is obesity a risk factor for pressure injury

Answer 10

Weight is not a good indicator of proteins stores or nutritional health so patient can be deficient in nutrients essential to wound healing
Adipose tissue is poorly vascularized compared with the upper dermis and dermis having greater risk for tissue ischemia

Question 11

How often should Braden scale be done

Answer 11

On admission to agency 24-48 hours after admission at regular intervals and when there is a significant change in patient condition

Question 12

What other things to assess when yo notice non Lana lobe hyperemia

Answer 12

• palpate tissue be msg to and observed area to gather dither data about induration ( hardening of tissue caused by edema or inflammation)
• note changes in color, temp and hardnesss of surrounding skin

Question 13

Normal healthy skin should be

Answer 13

• unbroken or intact
• adequately nourished and hydrated
• resistance to injury
• adequate circulation is necessary to Maintain cell life sending in oxygen and removing toxins

Question 14

Antiembolic socks

Answer 14

• Measure legs before applying

- Apply socks before patient gets out of bed

Question 15

Normal intact skin

Answer 15

1) epidermis - acts as barrier
2) dermis- middle, hair follicles, oil/sweat glands, blood vessels, nerves
3) hypodermics/ subcutaneous- blood vessels, fat, connective tissue

Question 16

Functions of the skin

Answer 16

1) protection- acts as a barrier, waterproof, cushioned, protect internal/underlying structures
2) body temp regulation- fat storage, blood vessels with dilate/constrict to promote or slow heat loss
3) psychosocial- external appearance, self esteem
4) sensation- nerve endings, touch, pain, pressure, temp
5) vitamin D protection- ultraviolet rays and a precursor present in the skin produce vitamin D
6) immunological- ask as a bear to pathogens, open area serve as an entry for bacteria
7) absorption- medicine
8) elimination- sweat, water, electrolytes, waste

Question 17

Wound classification

Answer 17

• intentional wound
• unintentional wound
• open wound
• closed wound
• acute vs chronic

Question 18

Intentional wounds

Answer 18

Purposely created

Edges normally clean, bleeding well controlled (surgical)

Question 19

Unintentional wound

Answer 19

Accidentally
Unexpected
Edges jagged, risk for higher contamination

Question 20

Open wound

Answer 20

Intentional or unintentional
Skin surface broken, provide entry for microorganisms
Higher risk for infection

Question 21

Closed wound

Answer 21

Blow, force, stain

Skin not broken

Question 22

Acute wound

Answer 22

Heal within days to weeks

Question 23

Chronic wound

Answer 23

Don not progress though normal stages of healing

Remain in inflammatory stage

Question 24

What causes pressure ulcers

Answer 24

• Pressure
• Shearing- skin layer moving in opposite direction tearing vessels
• Friction

Question 25

Pressure ulcer risk factors

Answer 25

1) immobility- all bedbound/chair bound persons or those with limited ability to re-position/move themselves
2) impaired mental health
3) poor nutrition- need adequate protein/ vitamins/ hydration to promote wound healing
4) incontinent - extra skin moisture
5) patients who already have other underlying conditions
6) age- elderly have thinner/ dryer skin, less fat, decreased elasticity

Question 26

Pressure ulcer prevention (PUP)

Nursing interventions

Answer 26

• perform skin assessment and Braden score every shift
• prevent frost ion and shearing
• hygiene
• use appropriate equipment
• head of bed in low Fowler’s
• turn a hike posted
• teach patient to shift weight
• nutritional status
• use protective barrier

Question 27

Pressure ulcer and medical devices

Answer 27

• always check any medical equipment/devices patient is using and surrounding skin
• use padding or securement device is if available
• make sure patients aren’t positioned on top of their equipment

Question 28

Slough

Answer 28

Non-visible tissue, usually yellow green brown/tan in color can be loose/moist or dry/stringy and a parents

Question 29

Eschar

Answer 29

Thick leathery necrotic tissue on one surface black/brown in color

Question 30

Granulation

Answer 30

Formation of small blood vessels in connective tissue in a full thickness wing bright red, bumpy appearance
New blood vessels

Question 31

Epithelial tissue

Answer 31

New skin growing in superficial room can be pink and shiny