Wound and Skin Care

Question 1

What are the structures of the skin

Answer 1

Epidermis, dermis, subcutaneous

Question 2

What are the functions of the skin?

Answer 2

Protection
Body temp regulation
Vitamin D prod
Sensation
Immunologic
Absorption
Elimination

Question 3

T or F younger people have more resistance to skin injury

Answer 3

T

Question 4

T or F does the skin need to be adequately nourished

Answer 4

T

Question 5

T or F the skin does not need adequate circulation

Answer 5

F

Question 6

T or F in children under 2 y/o the skin is thinner and weaker than adults?

Answer 6

T

Question 7

T or F an infant’s skin and mucus membranes are injured and infected easily

Answer 7

T

Question 8

In older adults what happens to their skin?

Answer 8

Epidermis gets thinner, collagen formation impaired, subcutaneous fat is decreased

Question 9

Who is the most susceptible to skin injury in adults?

Answer 9

very thin or obese people

Question 10

What does dehydration do to the skin?

Answer 10

Cause break down

Question 11

T or F pt with jaundice are more likely to scratch and cause lesions?

Answer 11

T

Question 12

T or F eczema and psoriasis do not cause lesions

Answer 12

F

Question 13

What are the principles in wound healing?

Answer 13

1. intact skin is the first line of defense against infection
2. hand hygiene is required
3. the body responds systematically to trauma of any of its parts
4. an adequate blood supply is essentail for normal body response
5. normal healing is promoted when the wound is not covered
6. extent of damage and pt helath will effect healing
7. proper nutrition

Question 14

Phases of wound healing

Answer 14

1. hemostasis
2. inflammatory
3. proliferation
4. maturation

Question 15

hemostasis

Answer 15

blood vessels constrict
blood clotting
exudate formed (pain and swelling)
increased perfusion
decreased platelets

Question 16

inflammatory phase

Answer 16

after hemo
1-2 days
WBC move to wound (macrophages)
ingest debris
fibroblasts fill wound
exudate
generalized body response

Question 17

Proliferation

Answer 17

repair phase
many weeks
new tissue fills wound space
capillaries grow into wound
granulation and scar tissue

Question 18

Maturation

Answer 18

3 weeks after injury
collagen shows up and compresses blood vessels
new scar

Question 19

T or F children and healthy adults heal faster

Answer 19

t

Question 20

What drugs delays healing?

Answer 20

corticosteroid drugs and postoperative radiation therapy delay healing

Question 21

What are some wound complications

Answer 21

infection, hemmorrhage, dehiscence and evisceration, fistula formulation

Question 22

Where are the most common places for pressure ulcers

Answer 22

bony prominences

Question 23

What are the mechanisms in pressure injury development

Answer 23

external pressure
friction or shearing
microclimate

Question 24

what is external pressure

Answer 24

compression of blood vessels

Question 25

friction or shering is what

Answer 25

forces tering or injuring blood vessels

Question 26

microclimate is what

Answer 26

temperature and moisture of the skin

Question 27

Stage 1 pressure injuries

Answer 27

nonblanchable erythema of intact skin

Question 28

Stage 2 pressure ulcer

Answer 28

partial-thickness skin loss with exposed dermis

Question 29

Stage 3 pressrue ulcer

Answer 29

full thickness skin loss; not involving underlying fascia

Question 30

Stage 4

Answer 30

full-thickness skin and tissue loss

Question 31

Unstageable

Answer 31

obscured full-thickness skin and tissue loss

Question 32

Deep tissue pressure injury

Answer 32

persistent nonblacnchable deep red, marron, or purple discoloration

Question 33

Skin assessment

Answer 33

inspect and palpate head to toe bony prominences

Question 34

How often do you do a skin assesment

Answer 34

acute care: every shift long-term settings: weekly for 4 weeks home health: each visit

Question 35

Types of drainage

Answer 35

serous - clear normal sanguineous - bloody (indicates site is bleeding) serosanguineous - clear and bloody (normal) purulent - thick yellow, green, brown (infection)

Question 36

Exudate is

Answer 36

pus

Question 37

How can the nurse prevent pressure injuries

Answer 37

1. assess at risk pts daily 2. cleanse the skin 3. maintain higher humidity, use moisturizers 4. protect skin from wetness (incontinence) 5. proper positioning/turning 6. appropriate support surface 7. nutritional supplements 8. improve mobility and activity

Question 38

When dressing a wound it is important to

Answer 38

- know if you need to add moisture or remove moisture - protect surrounding skin from the wound - remove any damaged or necrotic tissue

Question 39

Types of drains

Answer 39

penrose (open hose) jackson pratt and hemovac (closed system)