Skin Integrity And Wound Care

Question 1

Classification of pressure ulcers

Answer 1

Stage one non-blanchable redness of intact skin. Stage two partial thickness skin loss or blister. Stage III full thickness skin loss, fat visible. Stage for full thickness tissue loss, muscle or bone visible. Unstageable or unclassified is full thickness skin or tissue loss, depth unknown. Suspected deep tissue injury is depth unknown.

Question 2

Granulation tissue

Answer 2

Red, moist tissue composed of new blood cells, the presence of which indicates progression toward healing.

Question 3

Slough

Answer 3

Soft yellow or white tissue is characteristic of this. Stringy substance attached to wound bed. Must be removed by skilled clinician before the wound is able to heal.

Question 4

Eschar

Answer 4

Black or brown necrotic tissue. Needs to be removed before healing can proceed.

Question 5

How to measure wound depth

Answer 5

Measure by using a cotton tipped applicator are in the wound bed

Question 6

Exudate (wound)

Answer 6

Should describe the amount, color, consistency, and order of wound drainage and is part of the wound assessment

Question 7

Wound classification

Answer 7

Primary intention, is a wound that is closed, such as a surgical incision. Risk of infection is low, healing occurs quickly with minimal scar formation.
Secondary intention, is a wound with edges not approximated, such as a pressure ulcer. Wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal, that’s the chance of infection is greater.

Question 8

Partial-thickness wound

Answer 8

Shallow wounds involving loss of epidermis and possibly partial loss of dermis. Heal by regeneration.

Question 9

Full-thickness wounds

Answer 9

Extend into dermis and heal by scar formation. Do not regenerate.

Question 10

Partial thickness wound repair steps

Answer 10

1. Inflammatory response
2. Epithelial proliferation
3. Migration
4. Re establishment of the epidermal layers

Question 11

Full thickness wound repair steps

Answer 11

1. Hemostasis
2. Inflammatory
3. Proliferative
4. Remodeling

Question 12

Acute wound

Answer 12

Proceeds through an orderly and timely repair to process that results in sustained restoration of anatomical in functional integrity

Question 13

Chronic wound

Answer 13

Fails to proceed through in orderly and timely process to produce anatomical and functional integrity

Question 14

Complications of wound healing

Answer 14

• hemorrhage
• infection
• dehiscence
• evisceration

Question 15

Hemorrhage

Answer 15

Bleeding from a wound site, although normal during and immediately after initial trauma, can also occur after hemostasis, either externally or internally.

Question 16

Wound infection

Answer 16

The second most common healthcare associated infection. It wound is infected if purulent material drains from it.

Question 17

Dehiscence

Answer 17

The partial or total separation of wound layers, this most commonly occurs before collagen formation.

Question 18

Evisceration

Answer 18

Protrusion of visceral organs through a wound opening, causing total separation of wound layers.

Question 19

Considerations for the Braden scale.

Answer 19

Sensory perception, moisture, activity, mobility, nutrition, friction and shear.

Question 20

Factors influencing pressure ulcer formation and wound healing

Answer 20

Sheer force, friction, moisture, nutrition, tissue perfusion, infection, and age.

Question 21

Risk factors for pressure ulcer development

Answer 21

In paired sensory perception, impaired mobility, alteration in level of consciousness, shear, friction, and moisture.