Skin Intergrity/Wounds

Question 1

Closed wound

Answer 1

when there are no breaks in the skin. contusions (bruises) or tissue swelling from fractures are common closed wounds

Question 2

Open wound

Answer 2

occurs when there is a break in the skin or mucous membranes. open wounds include abrasions, lacerations, puncture wounds, and surgical incisions

Question 3

Partial thickness wounds

Answer 3

extend through the epidermis but not through the dermis

Question 4

Full thickness wounds

Answer 4

extend into the subcutaneous tissue and beyond

Question 5

Impaired skin intergrity

Answer 5

altered epidermis and/or dermis

Question 6

impaired tissue integrity

Answer 6

Damage to mucous membrane, cornea, integumentary, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament

Question 7

arterial ulcers

Answer 7

blockage of arterial blood to an area (clot or stenosis of the arterioles) causes tissue necrosis. Will be cooler when touch. Patient will have lose of hair.
CM numbness, weakness, generalized skin discoloration, changes in growth of hair and nails.
Ulcer appears punched out, small and round with borders. Surrounding skin is shiny, thin, and dry, cool to touch.

Question 8

venous ulcer

Answer 8

caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function.
Usually located in the inner ankle or lower calf. wound bed is “beefy”. Surrounding skin is reddended or brown and edematous

Question 9

pressure injury

Answer 9

caused by intense or prolonged pressure in combination with shear, resulting in tissue ischemia and injury
- turn and reposition at least every 2 hours, teach patient to shift weight every 15 minutes

Question 10

stage 1 pressure injury

Answer 10

intact skin with localized area of nonblanchable erythema

Question 11

stage 2 pressure injury

Answer 11

partial thickness skin loss with exposed dermis; serum filled or ruptured blister

Question 12

stage 3 pressure injury

Answer 12

full thickness loss of skin, no bone or muscle is visible

Question 13

stage 4 pressure injury

Answer 13

full thickness skin and tissure loss with exposed bone, muscle, tendon, ligament, or cartilage

Question 14

Slough

Answer 14

soft, moist, devitalized (necrotic) tissue; may seem white, yellow, tan: may be stringy, loose, or adherent to bed.

-Debride the wound

Question 15

eschar

Answer 15

necrotic tissue; dry, thick, leathery; may be black, brown, or gray depending on moisture level

-debride the wound

Question 16

tunneling

Answer 16

a channel where tissue has been lost and can extend through any direction, and extend to soft tissue to any muscle. Measure dept by using a gloved finger.

Question 17

undermining

Answer 17

its not a channel, simply an overhang. Tissue has been destroyed underneath.

Question 18

Unstageable pressure injury

Answer 18

full thickness wound covered by slough or eschar. Will be stage 3 or 4

Question 19

Deep tissure injury (DTI)

Answer 19

• localized area of persistent non-blanchable deep red, maroon, purple discoloration blood filled blister.
• skin may be in tact or nonintact

Question 20

Medical device related pressure injury

Answer 20

• states the etiology of injury

- staged using the system

Question 21

Mucosal membrane pressure injury

Answer 21

• pressure injury found on mucous membranes with history of a medical device in use at the location of the injury.
• can not be staged.

Question 22

When is clients skin assessed?

Answer 22

• on admission
• daily
• as needed based on assessment findings.

Question 23

what are the two common tools used in a skin assessment?

they are also called _______ _______ tools.

Answer 23

• Braden and Norton scales

Question 24

Do we delegate skin assessment?

Answer 24

NO!

Question 25

Where are you most likely to find pressure injuries?

Answer 25

• bony prominences
• areas under weight
• medical appliances
• damp skin
• intertriginous

Question 26

Assessing dressing/wound you assess the..

Answer 26

amount
odor
consistency
-color

Question 27

Penrose

Answer 27

a plastic tube that allows drainage from the opening.

-placed into patient body in a seperate opening other than the incision

Question 28

Jackson pratt

Answer 28

looks like a little hand grenade, placed into patietns skin by very small puncture wound. Used by suction

Question 29

Hemovac

Answer 29

looks like a stack of pancakes, used by suction

Question 30

do not use ….. to irrigate wounds

Answer 30

alcohol or hydrogen peroxide unless instructed to

Question 31

use …. to irrigate wounds

Answer 31

water, saline, or sterile saline

Question 32

Autolytic debridement

Answer 32

auto- body ltyic- breaking down.

Question 33

Surgical incision

Answer 33

an open, intentional wound caused by a sharp instrument

Question 34

Laceration

Answer 34

skin or mucous membranes are torn open , resulting in a wound with jagged margins

Question 35

Abrasion

Answer 35

scrape of the superficial layers of skin.

Question 36

Puncture wound

Answer 36

an open wound caused by a sharp object . Often there is a collapse of tissue around entry point making prone to infection

Question 37

Dehiscence

Answer 37

Separation of one or more layers of a wound approximately 3-11 days after injury of surgery. Often occurs with activity and is seen in obese individuals due to the increased pressure.
Cover it up with a sterile dressing, and notify the surgeon

Question 38

Debridement

Answer 38

the removal of a foreign matter or dead tissue from a wound