skin & wounds

Question 1

skin functions

Answer 1

protection
thermoregulation
metabolism
sensation

Question 2

friction wound

Answer 2

very superficial

Question 3

shearing wound

Answer 3

layers of the skin has separated

Question 4

diminished sensation

Answer 4

decreases patient’s response to pain

Question 5

examples of diseases that diminish sensation

Answer 5

diabetic neuropathy
stroke
alzheimer’s

Question 6

intrinsic injury examples

Answer 6

decreased motility
poor nutrition
aging

Question 7

extrinsic injury examples

Answer 7

shearing & friction injuries
hygiene
moisture
positioning

Question 8

extrinsic injury examples

Answer 8

shearing & friction injuries
hygiene
moisture
positioning

Question 9

for a patient in the hospital, what braden score indicates risk for a pressure injury?

Answer 9

18 or less

Question 10

acute wound

Answer 10

surgical incision that goes through all 3 phases of healing in a short duration without complication

Question 11

chronic wound

Answer 11

natural healing process is much slower because it is occurring from inside out

Question 12

clean wound

Answer 12

uninfected, minimal inflammation, may be open or closed

Question 13

clean-contaminated wound

Answer 13

incision with a high risk of infection requiring antibiotics, breached barrier

Question 14

contaminated wound

Answer 14

traumatic or surgical wound where there was a break in sterile procedure

Question 15

infected wound

Answer 15

overgrowth of microorganisms, bacteria has overwhelmed immune defense

Question 16

what do you NOT give to a patient with a colonization of proliferating bacteria?

Answer 16

antibiotics

Question 17

superficial wound

Answer 17

only epidermis

Question 18

partial-thickness wound

Answer 18

through epidermis, but not fully dermis

Question 19

full-thickness wound

Answer 19

through dermis and maybe sub q tissue

Question 20

penetrating wound

Answer 20

foreign body pierced through all layers of skin

Question 21

contusion

Answer 21

localized, bruising

Question 22

stage 1 pressure ulcer

Answer 22

area of redness does not blanch

Question 23

stage 2 pressure ulcer

Answer 23

small break in skin= partial thickness into epidermis or dermis, but relatively shallow

Question 24

stage 3 pressure ulcer

Answer 24

down to sub q tissue. can go down to muscle, but not through it

Question 25

stage 4 pressure ulcer

Answer 25

full thickness into muscle, may be able to see tendons and bone

Question 26

maceration

Answer 26

moisture causes skin to be pale and wrinkled, not healthy tissue

Question 27

undermining

Answer 27

erosion underneath the wound margins resulting in tissue damage beneath the skin

Question 28

blistering

Answer 28

small bubble on skin filled with serum common in burn vitims

Question 29

crepitus

Answer 29

crackling sensation under the skin

Question 30

erythema

Answer 30

redness

Question 31

epiboly

Answer 31

wound with rolled or curled under edges that may be dry or calloused

Question 32

used for low tension, small wounds and fall off on their own

Answer 32

steri strips

Question 33

why do you remove every other one when removing sutures?

Answer 33

make sure skin edges stay closed when supports are removed

Question 34

purulent

Answer 34

thick yellow, white, or green pus

Question 35

sanguineous

Answer 35

blood drainage

Question 36

serous

Answer 36

straw-colored, serum portion of blood

Question 37

primary intention

Answer 37

closed, surgical incision and well approximated

Question 38

secondary intention

Answer 38

cannot be closed, needs to heal from inside out

Question 39

tertiary intention

Answer 39

close wound at a later date

Question 40

phases of healing

Answer 40

1 inflammation 1-5 2 proliferation 5-21 3 maturation up to 6 months

Question 41

fistula

Answer 41

passage between two body cavities

Question 42

common fistula area

Answer 42

between vagina and rectum

Question 43

internal bleeding

Answer 43

cannot see; lowered BP, raised pulse, increases tenderness and pain

Question 44

what do you assess for internal bleeding?

Answer 44

vital signs, hemoglobin/hematocrit

Question 45

negative pressure wound therapy

Answer 45

woundvac stimulates granulation tissue and decreases edema to promote healing

Question 46

hyperbaric oxygen therapy

Answer 46

stimulates new blood vessels and white cells to promote healing in serious wounds

Question 47

debridement surgical option

Answer 47

removal of dead tissue

Question 48

hydrotherapy

Answer 48

like a powerwasher to removed dead tissue

Question 49

enzymatic

Answer 49

gel helps to dissolve dead tissue

Question 50

autolysis

Answer 50

body naturally dissolves dead tissue

Question 51

biotherapy

Answer 51

sterile maggots or leeches

Question 52

primary dressing

Answer 52

covering the wound

Question 53

secondary dressing

Answer 53

placed over the primary

Question 54

what are hydrocolloids helpful for?

Answer 54

stage 2 pressure wounds

Question 55

hydrogels

Answer 55

add moisture to wound

Question 56

transparent films

Answer 56

used over IV site

Question 57

what does low protein, albumin, & prealbumin indicate?

Answer 57

poor wound healing

Question 58

normal WBC count range

Answer 58

4-11

Question 59

what does elevated ESR indicate?

Answer 59

inflammatory reaction

Question 60

localized wound dehydration

Answer 60

desiccation