Skin Integrity and Wound Care

Question 1

The skin edges are closed, and the risk of infection is low… To draw 2 tissue surfaces close together as in the repair of a wound:

Answer 1

Approximate(d)

Healing by primary intention.

Or to draw the bones of a joint together as in physical therapy.

Question 2

What are the 6 evaluations done on the Braden scale?

Answer 2

1. Sensory perception (ability to respond meaningfully to pressure-related discomfort)
2. Moisture (degree to which skin is exposed to moisture)
3. Activity (degree of physical activity)
4. Mobility (ability to change and control body position)
5. Nutrition (usual food intake pattern: NPO, IV, TPN [total parenteral nutrition])
6. Friction and Shear

Question 3

What number scale is predicted as a severe risk for pressure sores?

Answer 3

Total score of 9 or below.

Mild risk is 15-18

Question 4

Arterial leg ulcer characteristics:

Answer 4

WHERE: at tips of toes or inbetween, over phalangeal heads, above laterial malleolus, over the metatarsal heads, on the side of sole of feet

WHY: commonly a history of: aging, diabetes, arteriosclerosis, smoking, hypertension

LOOK LIKE: deep pale base, well defined edges, black/necrotic tissue

LEG HAS: minimal/no hair, thin/dry/shiny skin, thickened toe nails, leg may be cool, leg becomes pale when elevated, may have neuropathy, nil/diminished leg and foot pulses

PAIN: very painful, pain is reduced by lowering the leg to a dependent position.

Question 5

Venous leg ulcer characteristics:

Answer 5

WHERE: Lower 1/3 of leg, pretibial area, anterior to medial malleous

WHY: commonly a history of: deep vein thrombosis, obesity, calf muscle pump function deficits, valvular incompetence in superficial perforating veins.

LOOK LIKE: ulcer has uneven edges, ruddy granulation tissue, no dead tissue

LEG HAS: reddish brown pigmentation (Haemosiderin), evidence of healed ulcers, oedema that may leak and cause maceration, varicose eczema, itchy skin and scale, dilated and tortuous superficial veins, leg may be WARM, HAIR on leg, normal leg and foot pulses.

PAIN: moderate to no pain, if pain is present: eased by RAISING the leg.

Question 6

Decreased blood supply to a body part such as skin tissue or to an organ such as the heart:

Answer 6

Ischemia

Question 7

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Answer 7

Abrasion

Question 8

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Answer 8

Blanching

Question 9

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Answer 9

Blanchable hyperermia

Question 10

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Answer 10

Collagen

Question 11

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Answer 11

Debridement

Question 12

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Answer 12

Dehiscence

Question 13

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Answer 13

Drainage evacuators