skin integrity and wound care

Question 1

epidermis

Answer 1

top layer of skin

Question 2

dermis

Answer 2

inner layer of skin

collagen

Question 3

dermal - epidermal junction

Answer 3

separates dermis and epidermis

Question 4

intact skin protects patient from what

Answer 4

chemical and mechanical injury

Question 5

critically think when assessing skin

Answer 5

when toileting, dressing, showering, changing brief
lift up folds
pendulous breasts
pannus
turn patient and assess backside

Question 6

identifying abnormals within skin characteristics

Answer 6

if skin is reddened, showing signs of breakdown notify provided and intervene appropriately to prevent further issues

Question 7

what is a wound

Answer 7

interruption of the integrity of the skin

Question 8

types of wounds

Answer 8

surgical incisions
nonsurgical
cut/laceration
skin tears
ulcer
pressure ulcer
arterial wound/ulcer
venous wound/ulcer
diabetic wound/ulcer

Question 9

assessing wounds

Answer 9

what kind, how did it occur?
location
color
size
drainage
odor
pain
skin around wound
old dressing when removed
drainage/exudate amount on old dressing

Question 10

colors of wound

Answer 10

beefy red- indicates tissue and skin healing, appropriate blood supply
pink - no active s/s of infection, blood supply isn’t ideal
yellow- slough or infection
black- dead tissue no blood supply

Question 11

drainage and exudate type

Answer 11

sanguineous
serosanguineous
serous
purulent

Question 12

skin around wound

Answer 12

irritation from adhesive?

increased warmth tender to touch inflammation?

Question 13

old dressing when removed

Answer 13

any drainage: amount, color, odor on dressing

Question 14

absent drainage

Answer 14

no drainage or exudate present

Question 15

scant amount of exudate present

Answer 15

the wound is moist, even though no measurable amount of exudate appears on dressing

Question 16

small or minimal amount of exudate

Answer 16

exudate covers less than 25% of the dressing

Question 17

moderate amount of drainage

Answer 17

wound tissues are wet and drainage involves 25-75% of the dressing

Question 18

large amount of drainage

Answer 18

wound tissue is filled with fluid and exudate covers more than 75% of dressing

Question 19

copious amount of drainage

Answer 19

wound dressing is filled with fluid and dressing is saturated with exudate

Question 20

factors that influence healing process

Answer 20

nutrition
tissue perfusion
infection
age
stress
albumin and total protein labs for nutrition and healing of wounds

Question 21

age affecting wound healing

Answer 21

children and healthy adults heal more rapidly

Question 22

circulation and oxygenation

Answer 22

adequate blood flow is essential

Question 23

nutritional status

Answer 23

healing requires adequate nutrition

Question 24

wound condition

Answer 24

specific condition of wound affects healing

Question 25

health status

Answer 25

corticosteroid drugs and postoperative radiation therapy delay healing

Question 26

skin tears

Answer 26

occur when layers of the skin separate or peel back

Question 27

what causes skin tears

Answer 27

skin bumping into a hard object wound dressing changes and adhesive removal aggressively washing or drying the skin

Question 28

skin tear prevention

Answer 28

be careful with thin delicate skin place sleeves on individuals prone to skin tears decrease use of adhesive carefully remove adhesive

Question 29

care of skin tears

Answer 29

control the bleeding apply saline or warm water and clean area while gently attempting to replace the torn skin back into the original position pat dry with clean gauze measure size of skin tear add steri strips across site carefully cover skin with nonadhesive dressing use stockinette instead of adhesive dressing or tape if available document skin tear location, size, cleansing and dressing, how the patient tolerated also document how skin tear developed if info is available

Question 30

wound dressings can be very complex

Answer 30

many facilities have wound care nurses review orders in detail to understand what needs to be done if unsure ask for help

Question 31

leave dressing on unless

Answer 31

visibly soiled or orders indicate dressing needs changed may only need to change outer dressing some wounds may be left open to air and will require a cleaning only

Question 32

assess old dressing,

Answer 32

remove drainage noted to old dressing? amount, color, odor? assess wound characteristics

Question 33

clean wound per orders with

Answer 33

saline most likely pat dry with gauze apply topical ointments or special medicated dressings - indicated with orders apply top dressing securely - initial date time document

Question 34

risk of adhesive use on skin

Answer 34

can cause further damage, especially on chronic wounds and thin fragile skin be cautious when removing adhesive and how much adhesive you're using while applying dressing

Question 35

pressure injuries

Answer 35

impaired skin integrity related to unrelieved prolonged pressure localized damage to the skin and underlying soft tissue usually over a bony prominence or secondary to a foreign object creating pressure on the skin

Question 36

types of pressure injuries

Answer 36

pressure ulcer, decubitus ulcer, bed sore | may be present as intact skin, blister, or open ulcer. may be painful

Question 37

patients at risk for pressure injuries

Answer 37

decreased mobility decreased sensory perception fecal or urinary incontinence poor nutrition

Question 38

pressure intensity

Answer 38

pressure applied over a capillary occluding the vessel | causes tissue ischemia

Question 39

when a patient has reduced sensation and cannot respond to discomfort of ischemia,

Answer 39

tissue death will occur after a period of tissue ischemia, when patient is repositioned, area should be assessed if blood flow has returned to the area, it will turn erythematic in color due to vasodilation

Question 40

to assess area of pressure injury

Answer 40

press finger to area if area blanches (turns lighter in color) and erythema returns when finger is removed, this is balled blanch able if the eythematic area does not blanch when pressure is applied, this is called non-blanchable - deep tissue damage is probable

Question 41

pressure duration

Answer 41

both low pressure over a prolonged period and high intensity pressure over a short period can cause tissue damage pressure occludes blood flow, nutrients, and contributes to cell death

Question 42

tissue tolerance

Answer 42

how well can the tissue endure pressure depends on integrity of the tissue and supporting structures what factors are present? shear, friction, moisture will make the skin more susceptible to damage from pressure applied how well can underlying vessels redistribute pressure? poor nutrition aging hydration status and low BP can decrease tolerance of tissue to pressure

Question 43

risk factors for pressure ulcer development

Answer 43

``` impaired sensory perception alterations in level of consciousness impaired mobility shear friction moisture ```