Skin Integrity and Wound Care

Question 1

approximated

Answer 1

define edges that are in close proximity

Question 2

blanching

Answer 2

turns white when pressed

Question 3

debridement

Answer 3

cleaning

Question 4

dehiscence

Answer 4

pulling a wound apart and seeing viscera

Question 5

eschar

Answer 5

black crusty tissue that cover a wound

Question 6

evisceration

Answer 6

viscera comes out of the body

Question 7

exudate

Answer 7

drainage/fluid

Question 8

fistula

Answer 8

tunnel or hole that connects two organs

Question 9

induration

Answer 9

the change in depth with pitting

Question 10

ischemia

Answer 10

lack of oxygen

Question 11

laceration

Answer 11

cut/scrape not clean, usually tears

Question 12

maceration

Answer 12

when skin softens from presence of moisture

Question 13

non-blachable erythema (redness)

Answer 13

area of redness that doesnt turn white when pressed

Question 14

slough

Answer 14

stingy yellow stuff around wound

Question 15

VAC

Answer 15

vacuum assisted closure

Question 16

What does the development of a pressure ulcer depend on?

Answer 16

pressure intensity

pressure duration

tissue tolerance

Question 17

What are some risk factors to develop pressure ulcers?

Answer 17

impaired sensory perception

impaired mobility

altered LOC

shear

friction

moisture

Question 18

Describe a stage 1 pressure ulcer

Answer 18

intact skin with non-blanchable ertythema

darker skin may not have visible blanching but a different color skin

skin is still intact

may be discomfort with swelling and congestion

Question 19

stage II pressure ulcer?

Answer 19

partial thickness skin loss, may involve epidermis or dermis

ulcer is superficial

abraision, blister or shallow crater

edema may be present

Question 20

stage III pressure ulcer?

Answer 20

full thickness tissue loss

sub Q fat may be visible

may extend to fascia

no exposure of bone, tendon, or muscle

may include underminning or tunneling

drainage or infection common

Question 21

Stage IV ulcer?

Answer 21

full thickness tissue loss

exposed bone, tendon or muscle is common

often includes undermining or tunneling

eschar or slough may be visible in parts of wound

Question 22

unstageable pressure ulcer?

Answer 22

cant visualize base of the wound

depth is obscured by slough of eschar

Question 23

What are some examples of a suspected deep-tissue injury with an unknown depth?

Answer 23

purple or maroon area blood-filled caused by damage of soft tissue from pressure or shear

may be boggy or mushy when compared to surrounding skin

Question 24

Is deep-tissue injury harder to detect in patients with darker skin tones?

Answer 24

YES

need to know baseline skin tone

good lighting

evaluate color specific changes in skin tone

Question 25

mongolian spot?

Answer 25

a blue spot that is a congenital birth mark

Question 26

describe eschar

Answer 26

black or brown necrotic tissue

Question 27

Acute wound?

Answer 27

heals faster and easier

Question 28

Chronic wound?

Answer 28

fails to proceed to reparative stage.

Question 29

tertiary intention?

Answer 29

wound that needs cleaned and left open until it is clean enough to be closed surgically excessive drainage and debris high risk of infection

Question 30

secondary intention?

Answer 30

wounds with tissue loss edges are wide formation of granulation tissue, wound contraction and epithelialization longer healing time, increased risk of infection scarring occurs

Question 31

What are the different stages of wound healing?

Answer 31

inflammatory (first 3 days) control bleeding form clots nutrients to wound site proliferative (3 day-3 wks) growth of granulation tissue contraction of wound edges resurfacing new epithelial cells maturation (remodeling (3wks - 6 months)) strengthening of collagen and restoration of normal appearance

Question 32

What are some risk factors of infection

Answer 32

Age impaired circulation or oxygenation wound condition/nature immunocompromised malnutrition chronic disease inadequate wound care

Question 33

What are some risk factors for dehiscence and evisceration?

Answer 33

chronic disease advanced age obesity invasive abdominal cancer vomiting dehydration/malnutrition abdominal surgery ineffective suturing

Question 34

What are the subscales of the braden scale

Answer 34

sensory perception moisture activity mobility nutrition friction and shear

Question 35

Do we massage reddened areas?

Answer 35

NO

Question 36

What is an abrasion?

Answer 36

superficial wound with minimal bleeding (partial-thickness)

Question 37

What is a puncture wound?

Answer 37

something that has puntures the skin (like a nail)

Question 38

What is woven gauze used for?

Answer 38

absorbing exudate dry moist to dry change

Question 39

What is non-adherent (tefla) dressing for?

Answer 39

doesnt adhere to wound bed

Question 40

transparent dressing?

Answer 40

"second skin" for small wounds

Question 41

Hydrocolloid dressing?

Answer 41

maintains granulation in wound bed on for up to 5 days swells in presence of exudate

Question 42

Hydrogel dressing?

Answer 42

provides moist wound bed reduces pain in wound debrides wound by softening necrotic tissue doesnt adhere to wound base

Question 43

When do you usually remove sutures and staples?

Answer 43

around 7 days staples close outer skin (less tissue trauma)

Question 44

why do we use binders?

Answer 44

create pressure over a body part immobilize a body part support a wound reduce edema securing splint securing dressing

Question 45

What is hard about abdominal binders?

Answer 45

they are hard to keep in place, most patients are obese and have egg shaped stomachs

Question 46

Should binders feel snug?

Answer 46

yes, but still should allow circulation | check distal areas for circulatory impairment

Question 47

do binders promote venous return?

Answer 47

YES

Question 48

does drainage affect healing?

Answer 48

yes

Question 49

How do drains work?

Answer 49

through negative pressure

Question 50

Do we take binders off every 2 hours?

Answer 50

yes, have patient take deep breath while you keep pressure on wound to keep from dehiscence