skin integrity & wound care

Question 1

all/portion of dermis intact

Answer 1

partial thickness wound

Question 2

entire dermis, sweat glands, hair follicles involved

Answer 2

full thickness wound

Question 3

full thickness loss where depth cannot be determined

Answer 3

unstageable wound

Question 4

edges well approximated (sewn/sutured together); minimal tissue loss; surgical procedure wounds

Answer 4

primary intention

Question 5

edges not approximated; open wounds from burn/trauma, likely involving contamination; take longer to heal, scar tissue

Answer 5

secondary intention

Question 6

delayed primary closure; wounds left open for days to allow for edema/infection to resolve or for fluid to drain first before closing wound

Answer 6

tertiary intention

Question 7

right after injury, blood clotting begins

Answer 7

hemostasis

Question 8

WBCS move to wound; characterized by pain, heat, redness, swelling at site; can have low grade fever, increased WBCs, fatigue

Answer 8

inflammatory stage

Question 9

regenerative phase lasting weeks; new tissue fills wound space

Answer 9

proliferation

Question 10

collagen remodeled, scar may form

Answer 10

maturation

Question 11

partial/total separation wound layer from excessive stress on unhealed wounds

Answer 11

dehiscence

Question 12

wound separates completely with viscera protruding through incision/wound

Answer 12

evisceration

Question 13

abnormal passage from an organ to outside body or from one organ/vessel to another; result of infection –> fluid accumulates in area, creating pressure. pressure on surrounding tissue leads to unnatural passage/connection formed

Answer 13

fistula

Question 14

one layer tissue slides over another layer

Answer 14

shear

Question 15

2 surfaces rub against eachother

Answer 15

friction

Question 16

intact with skin with non-blanchable redness of localized area; puts you at risk

Answer 16

stage I

Question 17

partial thickness wound with loss of dermis, open ulcer with pink wound bed

Answer 17

stage II

Question 18

full thickness tissue loss; SQ tissue may be visible, not bone or muscle; undermining/tunneling may be present

Answer 18

stage III

Question 19

full thickness tissue loss with exposed bone, tendon, or muscle. usually involves undermining/tunneling

Answer 19

stage IV

Question 20

full thickness tissue loss with base of ulcer covered in slough/eschar

Answer 20

unstageable

Question 21

clear, serous portion of blood; clear & watery

Answer 21

serous

Question 22

bright red blood, lots of RBCs in drainage, indicating fresh bleeding

Answer 22

sanguineous

Question 23

mixture of serum & RBCs; light pink to blood tinged

Answer 23

serosanginious

Question 24

infection present; made up of WBCs; thick, often foul smelling; color can be yellow/green, depends on bacteria present

Answer 24

purulent