Tissue Integrity

Question 0

A skin disorder where bacterial, fungal, viral, or parasitic agents are the cause

Answer 0

Infectious

Question 1

The three layers of the skin:

Answer 1

Epidermis, dermis, subcutaneous tissue

Epidermis – outermost layer
Dermis – second layer; deeper than epidermis
Subcutaneous tissue – also known as the hypodermis; deepest layer, beneath the dermis

Question 2

Skin disorder caused by skin cancers

Answer 2

Neoplastic

Question 3

Skin disorder usually caused by a path allergy such as acne, burn, or dermatitis

Answer 3

Inflammatory

Question 4

An intentional wound usually occurs during ___________.

Answer 4

Surgery

Question 5

_____________ wounds occur by accident.

Answer 5

Unintentional

Question 6

A _________ skin lesion occurs on previously healthy skin.

Answer 6

Primary

Question 7

What is a secondary skin lesion?

Answer 7

Results from a change in a primary lesion

Question 8

Wound depth that involves the dermis and epidermis; heals by regeneration (naturally)

Answer 8

Partial thickness

Question 9

Wound depth that involves the dermis, epidermis, subcutaneous fat, and in some cases, muscle and bone; connective tissue repair is necessary (surgery)

Answer 9

Full thickness

Question 10

What are the 4 terms used to describe a wound?

Answer 10

1. Clean
2. Clean-contaminated
3. Contaminated
4. Dirty or infected

Question 11

When describing a wound what would classify a wound as a “clean” wound?

Answer 11

No infection present; closed. Nothing open, an example of this would be a hematoma or a bruise.

Question 12

When describing a wound what would classify it as clean-contaminated?

Answer 12

This would be a surgical incision; no infection present; these are intentional wounds. Only contaminated because of break in the skin.

Question 13

When describing a wound what would classify it as a contaminated wound?

Answer 13

Can be intentional or unintentional; open; inflammation. An example would be a break in sterile technique during surgery but they continue with procedure. Another example of this would be if you’re walking down the street and cut your foot on glass, until there’s an infection it is just a contaminated wound.

Question 14

When describing a wound what would classify it as a dirty or infected wound?

Answer 14

Infection is noted; dead tissue is present; may have purulent drainage (pus)

Question 15

The _______ system and the skin are intricately linked through their roles as the protectors of the body.

Answer 15

Immune

Impaired tissue integrity can lead to immune response. Conversely, immune responses such as allergic reactions and inflammation can lead to issues with tissue integrity.

Question 16

What are the three phases of wound healing?

Answer 16

Inflammatory phase, proliferative phase, and maturation phase

Question 17

When a client experiences physical symptoms such as pain, swelling, redness, warm to touch, or possible fever what phase of wound is this?

Answer 17

Inflammatory phase- last 3 to 6 days after injury, bleeding is ceased, fibrin begins to form, scab begins to surface, blood supply increases to area

Question 18

During _________ phase of wound healing collagen is produced to strengthen wound, capillaries spread wound bed increasing blood supply, granulation tissue forms, scab covers wound bed. (Starts itching)

Answer 18

Proliferation phase (from day 3-4 of injury to up to 21 days)

Question 19

Maturation phase of wound healing

Answer 19

Also called remodeling phase, healing of the scar: often occurs at day 21 of injury and can last 1 to 2 years, collagen fibers re-organize themselves into a structure, wound is remodeled and contracted, scar strengthens.

Question 20

A break in the skin that can be superficial or deep; examples are an abrasion, laceration, or puncture

Answer 20

Open wound

Question 21

Injury with no break in the skin; examples are contusion and ecchymosis; may be caused by a blow or other type of trauma

Answer 21

Closed wound

Question 22

Steps of wound assessment

Answer 22

1. Inspect wound and gently palpate surrounding area regularly
2. Note presence and characteristics of wound drainage
3. Observe for signs of infection: redness, swelling, increased tenderness, or disruption of wound edges; note body temperature and white blood cell count as other indicators
4. Measurements
5. Count all sutures or staples

Question 23

How do you document wound measurements?

Answer 23

Size – length X width X diameter
Depth – using sterile cotton swab
Tunneling/undermining– Using sterile cotton swab, use clock as a frame of reference

Question 24

COCA is used to document observations of a wound, what does COCA stand for?

Answer 24

C– Color of wound bed and drainage O– Odor (determine after cleaning! And described as foul or none) C– Consistency of the drainage (thin or thick-clots) A– Amount of drainage (scant, small, large, copious)

Question 25

Complications that affect wound healing

Answer 25

Hemorrhage, infection, dehiscence, evisceration

Question 26

Noted by redness, swelling, heat, and pain at site; purulent exudate maybe noted

Answer 26

Complications that affect wound healing: Infection Client may be anorexic, nauseous, febrile, and have chills; healthcare provider will order a wound culture, and antibiotics will be administered after culture is obtained

Question 27

Accidental reopening of suture line (usually abdominal, but could occur with any wound) with tissue separation under wound

Answer 27

Complications that affect wound healing: Dehiscence Medical emergency! Results from infected suture line or factors that impede wound healing; clients often "feel something giving way"; place client in bed with head of bed low to eliminate gravity and with knees bent to decrease pool on suture line; cover wound with large, sterile, wet Celine dressings; notify surgeon immediately because repair of surgical site is necessary

Question 28

When internal organs protrude through incisional edges after dehiscence

Answer 28

Complications that affect wound healing: Evisceration Medical emergency! Contributing factors include infection, for nutrition, failure of suture material, dehydration, and excessive coughing; treated in a manner similar to dehiscence

Question 29

Wound dressing that is permeable to air and water vapor so it aids in preventing the growth of anaerobic organisms

Answer 29

Hydrocolloid (duoderm) dressing

Question 30

What is the purpose of dressing a wound with skin prep?

Answer 30

Helps to strengthen the skin to prevent breakdown

Question 31

What is the purpose of using a transparent dressing (such as tegaderm)?

Answer 31

Allows oxygen and moisture permeability but prevents moisture and bacteria entry

Question 32

What is the purpose of using a wet-to-dry gauze dressing?

Answer 32

Aids in debridement of necrotic tissue from wound bed; by allowing necrotic material to soften and adhere to the gauze

Question 33

What is the purpose of using proteolytic enzymes to treat pressure ulcers?

Answer 33

Aid in debridement for infected wounds with dead tissue

Question 34

What is vacuum assisted closure (VAC) therapy and how does it work to treat pressure ulcers?

Answer 34

Provides negative pressure environment to help reduce edema, increased blood supply and oxygen to the area, promotes a moist environment, decreases bacterial agents and helps with formation of granulation tissue

Question 35

An ischemic lesion of the skin and underlying tissue; appears over bony prominences, caused by external pressure.

Answer 35

Pressure ulcer

Question 36

Necessary for wounds covered with eschar and is sometimes needed for wounds covered with slough (dead) tissue; done by physician or specialized staff

Answer 36

Surgical debridement

Question 37

A moist dressing used to help trap wound drainage against the eschar to allow the body's own enzymes to break down the necrosis; can be done by the nurse if ordered

Answer 37

Autolytic debridement

Question 38

When sterile maggots are applied to wound bed to feed off of the bacteria present; this helps reduce bacteria and increase the surface pH

Answer 38

Larval therapy

Question 39

When synthetic skin or skin from a healthy area of the client is removed and placed over the nonhealing wound and sutured

Answer 39

Skin grafting

Question 40

Pressure ulcer with intact skin that is only affecting the epidermis and is non-blanchable, what stage would it be?

Answer 40

Stage I Use skin prep, hydrocolloid or transparent dressing

Question 41

A pressure ulcer with partial thickness loss of epidermis and/or dermis. Can present as an intact or ruptured blister. Superficial opening with red/pink wound bed. What stage pressure ulcer?

Answer 41

Stage II Use hydrocolloid or transparent dressing (unless infected)

Question 42

A pressure ulcer with full thickness tissue loss, where subcutaneous fat is visible. Slough or eschar is sometimes present. Undermining or tunneling may also be present.

Answer 42

Stage III pressure ulcer Treat with wet to moist gauze, hydrocolloid or proteolytic enzyme

Question 43

A pressure ulcer with full thickness tissue loss where tendon, muscle, or bone is visible and/or directly palpable. Most likely slough and/or eschar is present. Tunneling and/or undermining might occur.

Answer 43

Stage IV pressure ulcer Never use transparent or hydrocolloid dressing. Treat with wet to moist gauze or VAC therapy; sometimes surgery is necessary

Question 44

A pressure ulcer that includes full thickness tissue loss and has intact eschar and/or slough tissue may cover the whole wound bed.

Answer 44

Unstageable pressure ulcer Debridement is necessary to promote healing

Question 45

A pressure ulcer where skin is intact but purpleish or maroon in color. Damage is to underlying soft tissue from pressure or shearing, area will be painful.

Answer 45

Suspected deep tissue injury Treat with nonadhesive dressing, barrier creams or moisturizers

Question 46

Clear or straw-colored exudate

Answer 46

Serous

Question 47

Milky exudate full of cells and necrotic debris; color maybe blue, green, or yellow

Answer 47

Purulent

Question 48

Bright or dark red exudate containing red blood cells

Answer 48

Sanguineous

Question 49

When assessing edema if depth of pitting is around 2 mm; no obvious distortion after depression this is _______ _________ and referred to as ______.

Answer 49

Slight pitting 1+

Question 50

When treating a pressure ulcer which products would you use on a stage I?

Answer 50

Skin prep AND hydrocolloid (Duoderm) or transparent dressing (Tegaderm)

Question 51

When treating a pressure ulcer what products would you use on a stage II?

Answer 51

Hydrocolloid or transparent dressing

Question 52

When treating a pressure ulcer what type of product would you use on a stage III?

Answer 52

Wet-to-moist gauze dressing AND hydrocolloid or proteolytic enzyme

Question 53

When treating a pressure ulcer which products would you use for a stage IV?

Answer 53

Wet-to-moist gauze or VAC therapy; sometimes surgery is necessary Never use transparent or hydrocolliod dressing!

Question 54

What products would you use to treat a suspected deep tissue injury?

Answer 54

Non-adhesive dressing, barrier creams or moisturizers

Question 55

Risk factors for pressure ulcer development

Answer 55

Immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminish sensation, excessive body heat, advanced age, chronic medical conditions such as diabetes and cardiovascular disease

Question 56

Prevention is key for pressure ulcers! What are some ways to prevent pressure ulcers?

Answer 56

Providing nutrition, maintaining skin hygiene, avoiding skin trauma, providing supportive devices such as an overlay mattress, specialty bed, or Kinetic bed

Question 57

Used to determine a patients risk for developing a pressure ulcer

Answer 57

The Braden Scale

Question 58

What are the 6 criteria measured for the Braden scale when determining a patient's risk for developing pressure ulcers?

Answer 58

1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and shear

Question 59

Some age considerations when dealing with tissue integrity in the elderly include:

Answer 59

Decreased thickness and collagen, thinner with less elasticity, epidermal cell growth slows, decreased subcutaneous fat, decrease sensation, increased healing times, decreased thermoregulation

Question 60

Risk factors for alterations in tissue integrity:

Answer 60

Poor skin care and maintenance, sharing personal hygiene items, use of irritants or allergens that cause inflammation and irritation, excessive cleaning, improper cleaning, chronic illnesses and some treatments, medications

Question 61

Assessment of tissue integrity: * Obtain complete medical history; review all systems * Do thorough head to toe examination - inspect and palpate * Must have good lighting * Consider cultural differences

Answer 61

``` General inspection of color or odors Inspect for skin alterations Look closely at skin folds and creases Palpate skin temperature Palpate skin moisture Palpate skin turgor Assess for edema Palpate hair texture Inspect scalp for lesions Inspect now curvature, evenness, thickness ```

Question 62

Medication used to relieve inflammation and pruritis

Answer 62

Topical corticosteroids

Question 63

Medication to help prevent blockage of follicles

Answer 63

Antiacne

Question 64

Medication used to cause cell death at the DNA

Answer 64

Antibacterials

Question 65

Medication used to treat infection by interfering with bacterial replication and synthesis

Answer 65

Antibiotics

Question 66

Medication used to cause cell death specific to the organism present

Answer 66

Antifungals

Question 67

Medication used to inhibit viral DNA replication

Answer 67

Antivirals

Question 68

Medication used for decreasing pain with nerve blockage

Answer 68

Anesthetics

Question 69

Medications used to help moisturize the skin

Answer 69

Creams

Question 70

Medications used to help lubricate the skin to prevent water loss

Answer 70

Ointments

Question 71

What are the three types of wound healing?

Answer 71

1. Primary intention– Edges are well approximated (closed), typically intentional wounds with minimal tissue damage. Example: surgical incisions closed with sutures or staples 2. Secondary intention– Gapping open, need to be packed. Edges are not approximated, typically large open wounds. Example: Burns, pressure ulcers 3. Tertiary intention– Wounds that are infected or suspected to be infected. Wounds that are left open several days to allow edema or infection to resolve or exudate to drain; later closed with sutures or staples We always want primary intention and if it's not primary intention the goal is to get the wound to the primary intention stage!