Skin Integrity & Wound Care

Question 0

Phase 2 inflammatory

Answer 0

Last 4 to 6 days. WBC cells predominately leukocytes and macrophages, move to the wound. Leukocytes ingest bacteria and cellular debris

Question 1

Phase 1 hemostasis

Answer 1

Occurs immediately after the initial injury but vessels constrict and blood clotting begins. Through platelet activation and clustering

Question 2

Stage 3 proliferation phase

Answer 2

Fibroblastic, regenerative, or connective tissue phase. The proliferation phase last for several weeks. New tissue is built to fill wound space

Question 3

Stage 4 maturation phase

Answer 3

3 weeks after injury could continue for months or years. Collagen in the wound is remodeled making the healing wound stronger

Question 4

Friction, rubbing or scraping the epidermal layers of skin; top layer skin abraded

Answer 4

Abrasion

Question 5

A collection of pus in any part of the body that, in most cases, causes swelling and inflammation

Answer 5

Abscess

Question 6

The passage of blood from ruptures blood vessels into subcutaneous tissue, marked by purple discoloration of the skin (bruising)

Answer 6

Ecchymosis

Question 7

Redness of the skin

Answer 7

Erythema

Question 8

Excessive hairiness on women in areas that hair does not normally occur

Answer 8

Hirsutism

Question 9

A flat, distinct, discolored area of skin that is usually less than 1 cm wide

Answer 9

Macule

Question 10

Purple colored spots and patches that occur on the skin, and in mucous membranes, including the lining of the mouth

Answer 10

Purpura

Question 11

A small bump on the skin that contains our produces pus (pimple)

Answer 11

Pustule

Question 12

Crater like sores on skin or mucous membranes

Answer 12

Ulcer

Question 13

Are raised, often itchy, red welts on the surface of the skin

Answer 13

Urticaria

Question 14

A small pocket of fluid within the upper layers of the skin

Answer 14

Vesicle (blister)

Question 15

Loss of pigment from areas of the skin

Answer 15

Vitiligo

Question 16

A red, swollen mark left on flesh by a blow or pressure

Answer 16

Wheal

Question 17

Nutrition and hydration

Answer 17

Protein deficiency leading to a negative nitrogen balance, electrolyte imbalance and insufficient caloric Intake predisposes the skin to injury

Question 18

A defined area of intact skin with nonblanchable redness

Answer 18

Stage 1 pressure ulcer

Question 19

Partial thickness loss of dermis

Answer 19

Stage 2 pressure ulcer

Question 20

Full thickness tissue loss. Subcu fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present

Answer 20

Stage 3 ulcer

Question 21

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present and often include undermining and tunneling

Answer 21

Stage 4 ulcer

Question 22

Unstageable

Answer 22

Cannot tell (necrotic tissue)

Question 23

Assessment of mental status, continence, mobility, activity, nutrition (prevent pressure ulcers)

Answer 23

Braden scale

Question 24

Clear and watery drainage

Answer 24

Serous drainage

Question 25

Looks like blood

Answer 25

Sanguineous drainage

Question 26

Mixture of serum and RBCs. Light pink to blood tinged

Answer 26

Serosanguineous drainage

Question 27

Drainage is thick, musty or foul odor, varies in color

Answer 27

Prurient drainage

Question 28

Maceration

Answer 28

Overhydration

Question 29

Desiccation

Answer 29

Dehydration