skin power point

Question 1

Factors Affecting Skin Integrity

Answer 1

Integrity
Age
Mobility status
Sensation level
Impaired circulation
Medications (itching, rashes, sun sensitivity, allergies)
Fever (causes warm, wet areas- bacteria like this)
Infection
Lifestyle
Nutrition / Hydration

Question 2

Nutrition / Hydration that affect skin integrity

Answer 2

Protein (building blocks)

Vitamin C (boosts collagen)

Zinc (anti-inflammatory properties)

Dehydration (skin needs to be moist, water helps to flush away toxins and carry nutrients to the skin’s cells

Question 3

Wound Classification Skin integrity

Answer 3

Open wound: an actual break in the skin Closed wound: skin is still intact (bruising)

Question 4

Wound Classification Wound Depth:

Answer 4

Superficial wound: involves only the epidermis

Partial-thickness wound: involves the epidermis and dermis

Full-thickness wound: involves epidermis, dermis, subcutaneous tissue, and possibly muscle orbone

Question 5

Wound Classification Amount of Contamination

Answer 5

Clean: has no infection and the risk for infection is low

Clean contaminated: involves a surgery that involves organ systems likely to contain bacteria, higher infection risk

Contaminated: result from break in sterile technique, from perforation, trauma, accident, highest risk of infection

Infected: shows clinical signs of infection (warmth, redness, purulent drainage)

Question 6

other factors Affecting Wound Healing

Answer 6

Oxygenation
tissue perfusion
Diabetes

Question 7

Wound Healing phases

Answer 7

Inflammatory phase: the first phase, lasts about three days, include coagulation cascade

Proliferative phase: filling of wound bed with new (granulation) tissue

Maturation phase: remodeling phase; can last up to a year, collagen is deposited, and scar tissue forms

Question 8

Complications of Wound Healing

Answer 8

Infection
Fistula formation
Dehiscence
Evisceration

Question 9

what is Fistula formation

Answer 9

abnormal connection between organs in the body

Question 10

Dehiscence is

Answer 10

opening of wound

Question 11

Evisceration is

Answer 11

opening of wound AND protrusion of organs through the incision (put sterile gauze on and contact surgeon immediately)

Question 12

calculating the total body surface affected by burns

HEAD and NECK= %
right or left arm= %
entire trunk= %
gronin= %
LEG right or left= %

Answer 12

HEAD and NECK= 9%
right or left arm= 9% each
entire trunk= 36%
gronin= 1%
LEG right or left= 18% each

Question 13

the 4 types of burns

Answer 13

superficial thickness
partial
intermediate thickness
full-thickness
fourth degree

Question 14

superficial thickness burns is on

Answer 14

surface

Question 15

partial burns extend to

Answer 15

epidermis

Question 16

intermediate-thickness

Answer 16

epidermis and dermis

Question 17

full-thickness burns extend to

Answer 17

to lower dermis

Question 18

4th degree burns extends to

Answer 18

bones and muscle

Question 19

Pressure Injuries are caused by

Answer 19

Caused by long duration of pressure
medical devices
friction and shear
sensory loss
moisture
poor nutrition

Question 20

Pressure Injury Classification

Answer 20

stage 1
stage 2
stage 3
stage 4
unstageable
deeptissue

Question 21

stage 1 Pressure Injury looks

Answer 21

intact, non blistered skin with non blanchable erythema

Question 22

stage 2 Pressure Injury are

Answer 22

partial-thickness wound that involves the epidermis and/or dermis but does not extend below the level of the dermis

Question 23

stage 3 Pressure Injury are

Answer 23

full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue

Question 24

stage 4 Pressure Injuries are

Answer 24

full-thickness wounds that are deeper than Stage III and involve exposure of muscle, bone, or connective tissue

Question 25

Unstageable Pressure Injuries are

Answer 25

full-thickness wound in which the amount of necrotic tissue in the wound bed makes it impossible to assess the depth

Question 26

Deep Tissue Pressure Injuries looks like

Answer 26

an area of intact skin that is purple or maroon

Question 27

Interventions related to wound care

Answer 27

◦ Wound cleansing and irrigation ◦ Solution should be at room temperature or warmed ◦ Irrigation force should be strong enough to be effective without damaging new tissue ◦ Debridement ◦ Sharp ◦ Mechanical ◦ Enzymatic ◦ Autolytic ◦ Biologic

Question 28

Interventions to preserve skin integrity

Answer 28

Turning and positioning every 2 hours Skin hygiene

Question 29

Interventions related to wound care dressings

Answer 29

◦ Dressings ◦ Gauze dressings ◦ Transparent films ◦ Hydrocolloid dressings ◦ Foams ◦ Alginates ◦ Gels

Question 30

Heat and cold application information and requirements

Answer 30

Reduces pain, improves circulation, and reduces swelling May require a doctor’s order Complications

Question 31

what is required from doctor orders when applied heat/ cold applications

Answer 31

◦ Type of application ◦ Length of the treatment ◦ Frequency ◦ Body part to be treated

Question 32

Complications of heat/ cold applications

Answer 32

Loss of the body’s normal ability to sense temperature extremes, which may result in damage to tissue