Skin Integrity and Wound Healing

Question 1

** The nurse is caring for a client in the hospital. Which type of skin-related issue is most prevalent in healthcare?

Answer 1

pressure ulcer formation

Question 2

Function of melanin and sebum

Answer 2

protection

Question 3

Ways skin promotes thermoregulation

Answer 3

sweating

Question 4

lifespan changes for skin: babies

Answer 4

reduced ability to thermoregulate

more susceptible to rashes, blistering, chafing

Question 5

lifespan changes for skin: toddler/preschool

Answer 5

sunscreen

injuries from playing

Question 6

lifespan changes for skin: school/ adolescent

Answer 6

• lice, scabies, impetigo
• acne
• sunscreen

Question 7

lifespan changes for skin: adult/older adult

Answer 7

• dry skin more common
• wrinkling and poor skin turgor
• slower healing

Question 8

health related factors that can damage skin

Answer 8

• nutrition
• circulation
• allergy or infection
• abnormal growth rate

Question 9

mechanical forces that can damage skin

Answer 9

• pressure
• friction
• shear

Question 10

injury, such as knife, gunshot, burn, or surgical incision; heals within 6 weeks

Answer 10

acute wound

Question 11

wound that persists beyond usual healing time (>6 mo) or recurs without new injury to the area

Answer 11

chronic

Question 12

break present in the skin; tissue damage present

Answer 12

open

Question 13

no break seen in the skin, but soft tissue damage evident

Answer 13

closed

Question 14

closed surgical wound that did not enter GI, respiratory, or genitourinary tract

Answer 14

clean

Question 15

wound entering GI, respiratory, or genitourinary systems; infection risk

Answer 15

clean/contaminated

Question 16

Open, traumatic wound; surgical wound with break in sepsis; high infection risk

Answer 16

contaminated

Question 17

Wound site with pathogens present; signs of infection

Answer 17

infected

Question 18

pressure ulcer with sloughing, eschar, potential tunneling. bone/tendon/muscle NOT exposed

Answer 18

stage III

Question 19

pressure ulcer that’s blanchable

Answer 19

stage I

Question 20

pressure ulcer that exposes bone/tendon/muscle

Answer 20

stage IV

Question 21

pressure ulcer that’s partial-thickness loss of dermis

Answer 21

stage II

Question 22

stage of a full-thickness wound that doesn’t extend to the bone, tendon, or muscle. The wound tunnels and has some sloughing. What stage?

Answer 22

stage III

Question 23

Measures to prevent pressure ulcers

Answer 23

• repositioning and turning
• lift rather than drag patients when pulling up in bed
• specialty mattress/bed
• protective creams or lotions

Question 24

immediate phase of wound healing

Answer 24

hemostasis: vasoconstriction, platelet aggregation, clot formation

Question 25

up to day three of wound healing

Answer 25

inflammatory phase: vasodilation, phagocytosis

Question 26

day 4-21 of wound healing

Answer 26

proliferative phase: - partial thickness - epithelialization - full thickness - granulation/contracture

Question 27

21 days to 2 years of wound healing

Answer 27

maturation (full thickness only)

Question 28

small spot, like freckle or peticheae

Answer 28

macule

Question 29

larger than macule, like vitiligo

Answer 29

patch

Question 30

clean incision, early suture, hairline scar

Answer 30

primary intention

Question 31

gaping irregular wound, granulation, epithelium grows over

Answer 31

secondary intention (contraction and epithelialization)

Question 32

wound, granulation, closure with wide scar

Answer 32

tertiary intension (delayed closure)

Question 33

measures to keep wound edges close together

Answer 33

- binder - steri-strips - sutures, staples, clips - cyanoacrylate glue - elastic wraps, bandages, stretch netting

Question 34

purulent drainage, inflamed incisional area, fever, elevated leukocyte count

Answer 34

infection

Question 35

partial or total disruption in wound edges, the wound opens up

Answer 35

dehiscence

Question 36

protrusion of viscera through wound opening (inside goes outside)

Answer 36

evisceration

Question 37

passage between two areas that don't normally connect

Answer 37

fistula

Question 38

elements to assess with wound

Answer 38

- type/location/size/ classification/base - drainage - undermining or tunneling - infection or pain - if connect to a drain, measure output and confirm it's working

Question 39

bloody drainage

Answer 39

sanguinous

Question 40

pale pink-yellow drainage

Answer 40

serosanguinous

Question 41

pale yellow, watery (like fluid from a blister) drainage

Answer 41

serous

Question 42

tube placed in wound, no suction

Answer 42

penrose

Question 43

drain with suction present and bloody cavity

Answer 43

hemovac

Question 44

drain with bulb -- gentle suction when bulb is compressed and released

Answer 44

Jackson Pratt (JP)

Question 45

Who should remove a surgical dressing

Answer 45

surgeon first! they'll write orders

Question 46

dressing designed to be placed inside wound

Answer 46

alginate

Question 47

dressing made of woven cotton material. Nonocclusive

Answer 47

gauze

Question 48

dressing contains ionic silver -- either immediate or controlled release of silver into the wound bed

Answer 48

silver

Question 49

pad of compressed foam with moderate absorptive capacity

Answer 49

polyurethane foam

Question 50

type of dressing over IV site

Answer 50

transparent

Question 51

dressing with sodium carboxymethylcellulose fibers

Answer 51

hydrofiber dressing

Question 52

water-resistant gel-like dressing

Answer 52

hydrocolloid wafer

Question 53

which type of wound product requires a doctor's order

Answer 53

silver | All of them except transparent when you're in a hospital, but silver is never available OTC

Question 54

When would a wound involve packing or filling?

Answer 54

If tunneling or undermining are present

Question 55

wound therapy with hydrophobic sponge, negative pressure machine, transparent dressing

Answer 55

negative pressure wound therapy (wound vac)

Question 56

type of debridement not done by nurses

Answer 56

surgical

Question 57

debridement using a chemical product to break down debris

Answer 57

enzymatic

Question 58

debridement that's occlusive or hydrogel, debris gets eroded then irrigated with saline

Answer 58

autolytic

Question 59

debridement with wet-to-dry dressing

Answer 59

mechanical

Question 60

heat or cold: promotes healing and suppuration

Answer 60

heat

Question 61

heat or cold: controls bleeding

Answer 61

cold

Question 62

diet to promote wound healing

Answer 62

high in protein, vitamin A, C, E, zinc, water, arginine, carbs, fats

Question 63

problematic meds for wound healing

Answer 63

blood thinners (anticoagulants), chemo, corticosteroids and other immunosuppressants

Question 64

lifestyle choice that impairs wound healing

Answer 64

smoking

Question 65

stage this wound

Answer 65

2

Question 66

stage this wound

Answer 66

3

Question 67

stage this wound

Answer 67

1

Question 68

stage this wound

Answer 68

4