UNIT 3 - Ch. 32 Wound and Skin Care

Question 1

Define epidermis

Answer 1

Outer layer of the skin

Question 2

Define dermis

Answer 2

Tissue below the epidermis

Question 3

Define subcutaneous layer

Answer 3

Tissue below the dermis

Question 4

Define wounds

Answer 4

Disruption / injury to the skin

Question 5

Define Infection

Answer 5

Contamination in the wound

Question 6

Define open wound

Answer 6

Characterized by an actual break in the skin’s surface

Question 7

Define closed wound

Answer 7

Skin is still intact, as in a bruise

Question 8

Define superficial wound

Answer 8

Involves only the epidermis

Question 9

Define full-thickness wound

Answer 9

Deepest wound, which extends through the dermis to the subcutaneous layer and may extend farther to the muscle, bone, or underlying structures

Question 10

Define clean wound

Answer 10

There is no infection and the risk for development of an infection is low

Question 11

Define partial-thickness wound

Answer 11

Involves the epidermis and the dermis but does not extend through the dermis to the subcutaneous layer

Question 12

Define infected wound

Answer 12

A wound showing clinical signs of infection including redness, warmth, and increased drainage that may or may not be purulent (contain pus)

Question 13

Define serous drainage

Answer 13

Contains clear, watery fluid from plasma. Straw colored

Question 14

Define sanguinous drainage

Answer 14

Drainage usually indicating bleeding and is bright red

Question 15

Define Serosanguinous drainage

Answer 15

Drainage is pink to pale red and contains a mix of serous fluid and red, bloody fluid

Question 16

Define purulent drainage

Answer 16

Drainage is usually thick and indicates infection. It can be yellow, greenish, or beige. It contains pus

Question 17

Define primary intention in wound healing

Answer 17

Edges are close to each other. Wound heals quickly with little scarring or infection

Question 18

Define secondary intention in wound healing

Answer 18

It is an open wound and tissue loss is present. New tissue is filling the space. Risk of infection is high. Wound is deep

Question 19

Define Tertiary intention in wound healing

Answer 19

Delay in healing. (Ex: surgical wound that became infected) Must go through same process as secondary intention but may take longer.

Question 20

Define acute wound

Answer 20

Wound that progresses through phases of wound healing in a rapid, uncomplicated manner

Question 21

Define chronic wound

Answer 21

Fails to heal in a timely manner. Remaining open for extended period of time.

Question 22

Define inflammatory phase of healing

Answer 22

Begins with the body’s initial response to wounding of the skin; lasts about 3 days

Question 23

Define proliferative phase of healing

Answer 23

Purposes of this phase are to repair and defect; fill the wound bed with granulation tissue and resurface the wound with skin

Question 24

Define remodeling phase of healing

Answer 24

Granulation tissue continues to be deposited and remodeled; scar tissue is formed and strengthens. (Can last up to a year)

Question 25

Define scar tissue

Answer 25

An avascular mass of collagen that gives strength to the repaired wound

Question 26

Define pressure ulcers

Answer 26

Localized injury to the skin and or underlying tissue usually over a bony prominence; caused by combination of pressure, shear, and friction

Question 27

Define friction

Answer 27

The rubbing together of two surfaces: In the case of patients, it is the skin and the bed

Question 28

Define shearing forces

Answer 28

Unaligned forces pushing one part of a body in one direction, and another part of the body in the opposite direction: In the case of patients, it is when the skin sticks to the surface while the body’s weight continues to pull the body downward.

Question 29

List intrinsic risk factors for pressure ulcers

Answer 29

Examples:
-Poor nutrition
-edema
-Poor O2 delivery
-Incontinence
-infection

Question 30

List extrinsic risk factors leading to pressure ulcers

Answer 30

Examples:
-Moisture
-Friction
-Shear

Question 31

What 6 factors does the Braden scale assess for?

Answer 31

1. Sensory/Mental
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction/Shear

Question 32

Describe a stage I pressure ulcer

Answer 32

Characterized by intact, non-blistered skin with non-blanchable erythema or persistent redness in an area that has been exposed to pressure

Question 33

Describe stage III pressure ulcer

Answer 33

Full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. Undermining and Tunnel may be present

Question 34

Define undermining

Answer 34

An area of tissue loss present under intact skin, usually along the edges of the wound forming a “lip” around the wound

Question 35

Define Tunnel

Answer 35

While similar to undermining, it is a narrower passageway extending outward from the edge of the wound

Question 36

Describe stage II pressure ulcer

Answer 36

Partial-thickness wound that involves the epidermis and or dermis but does not extend below the level of the dermis.
-Shallow and superficial with a pink wound bed
-Intact or ruptured blisters due to pressure are also stage II ulcers

Question 37

Describe stage IV pressure ulcers

Answer 37

This wound is deeper then a stage III and involves exposure of muscle, bone, or connective tissue like tendons or cartilage.
-The depth of the wound, particularly if the bone is palpable, makes osteomyelitis likely

Question 38

Define osteomyelitis

Answer 38

An infection of the bone

Question 39

Define eschar

Answer 39

-Nectrotic tissue (dead tissue).
-Dry dark scab or falling away of dead skin

Question 40

Describe unstageable pressure ulcer

Answer 40

-Full-thickness wound with eschar
-Involvement of underlying structures
- Wound bed makes it impossible to assess depth of the wound until necrotic tissue is removed

Question 41

Define Suspected deep tissue injury

Answer 41

An area of intact skin that is purple/maroon, or a blood-filled blister

Question 42

Describe a suspected deep tissue injury

Answer 42

-Appears as stage I ulcers
-True depth of tissue damage is not apparent
-Injuries can progress rapidly, exposing deeper layers of tissue
-Can be difficult to identify in darker skinned people

Question 43

Define dermatitis

Answer 43

Inflammation of the skin

Question 44

Describe stasis dermatitis

Answer 44

Very common type of dermatitis.
Signs:
Thickened, reddish skin on ankles or shins, itching, open sores with oozing or crusting

Question 45

Define necrotizing fasciitis

Answer 45

Flesh-eating strep. Extreme emergency!!

Question 46

List out REEDA

Answer 46

Acronym for assessing any wound

Redness
Edema (swelling)
Ecchymosis (bruise)
Drainage
Approximation

-Warmth
-Pain

Question 47

Define contamination

Answer 47

The presence of microorganisms in the wound

Question 48

Define colonization

Answer 48

Microorganisms begin to increase in number but are causing no harm

Question 49

Define critical colonization

Answer 49

The bacteria begin to overwhelm the body’s defenses. May notice an increase in drainage, odor, color

Question 50

Define Ecchymosis in “REEDA”

Answer 50

a discoloration of the skin resulting from bleeding underneath, typically caused by bruising

Question 51

Describe what the nurse is looking for in Approximation in “REEDA”

Answer 51

Looking to see if the wound is starting to close

Question 52

Define a dehiserated wound (idk how to spell it lol)

Answer 52

you can see tissues pushing out of wound

Question 53

Define an eviscerated wound

Answer 53

you can see the organs pushing out of wound