wound care

Question 1

tissue integrity

Answer 1

the ability of the human body to regenerate and maintain normal physiologic functioning. the skin, cornea and subc tissue, and mucous membranes act as defense mechanisms for the body

Question 2

largest organ system of body accounting for about 15% of total body wight

Answer 2

skin

Question 3

skin main function

Answer 3

protection

providing barrier from injury, ultraviolet radiation and heat

Question 4

skin plays a crucial role in

Answer 4

sensory percreption such as touch, pain, pressure, and vibration

Question 5

skin regulates

Answer 5

temperature and protects the body against temperature changes
- eliminates waste and supports the underlying structures and synthesis of vitamin d

Question 6

epidermis

Answer 6

outer layer of the skin composed mainly of keratinocytes and other cells, such as melanocytes, Merkel cells and lanerhans cells

Question 7

dermis

Answer 7

largest portion of skin
- main function to sustain and support epidermis by providing strength and flexibility; made of connective tussye with capillaries; blood vessels; lymoth vessels; nerves; sweat and sebaceous glands; hair roots; elastic fibers; and collagen

Question 8

subcutaneous tissue

Answer 8

subc fat that insulates the body, absobs shock and pads the internal organs and structures

Question 9

risk factors for development of pressure injuries and wounds

Answer 9

• age
• mobility issues
• weight
• spina bifida, cerebral palsy, other chronic conditions such as liver, renal diseases, cancer and malnutrition

Question 10

as adults skin becomes

Answer 10

thinner, elasticity is lost, sub c fat becomes thinner, blood supply is more sulggish and the skin becomes less hydrated. therefore, shear, friction, pressure can cause problems

Question 11

pressure injury

Answer 11

• localized damage to skin, underlying tissue as a result of a pressure in combination with shear

Question 12

pressure injuries are most often

Answer 12

over bony prominences but can also be a result of a pressure caused by a medical device, such as urinary catheters, oxygen tubing, endotracheal tubing, drains.
- most susceptible are held, toes, sacrum, hips, elbow, shoulders, back of head

Question 13

stage 1

Answer 13

nonblanchable erythema of intact skin

Question 14

stage 2

Answer 14

partial thickness skin loss with exposed dermis

Question 15

stage 3

Answer 15

full thickness skin loss

Question 16

stage 4

Answer 16

full thickness skin and tissue loss

Question 17

unstageable

Answer 17

obscured full thickness skin and tissue loss

Question 18

deep tissue pressure injury

Answer 18

persistent nonblancable deep red, maroon or purple discoloration

Question 19

TIME ( how pressure injuries shoudl be described)

Answer 19

T: tissue integrity- describe how the tissue looks, the wound color, and if there is dead netcrotized tissue present

I: inflammation or infection- s/s of infection present, redness, warmth, swelling, discharge, and swelling

M: moisture- wound is dry or moist and if the wound is macerated

E: edge of wound- describe the wound edges

Question 20

DIDNT HEAL (factors influencing wound healing)

Answer 20

D= diabetes
I= infection 
D= drugs 
N= nutritonal problems
T= tissue necrosis
H= hypoxia
E= extensive tension 
A= another wound
L= low temperature

Question 21

hemosatic/ inflammatory

Answer 21

damaged tissue releases cytokines which trigger a process called hemostasis; blood coagulates, and the wound starts to heal
- plasma leaks into surrounding tissue and causes swelling

Question 22

proliferative

Answer 22

• new collagen fibers are formed
• nee wound bed is created
• capillaries start growing
• wound edges begin pulling closer and new granulation tissue grows

Question 23

remodeling

Answer 23

stronger collagen replaces soft gelatinous collagen; however this tissue is much weaker than the orginal tissue and is susceptible to reinjury

Question 24

primary healing or first intention

Answer 24

occurs in clean lacerations and surgical incisions; closed with skin ahesives or sutures

Question 25

secondary healing or second intention

Answer 25

wound healing that happens when the wound is left open to heal

Question 26

delayed primary closure

Answer 26

combination of primary and secondary healing, where the wound is left open for 5-10 days before it is closed with sutures

Question 27

skin redness

Answer 27

usually referred to as blanchable or nonblanchable erythema
- non-blanchable erythmea is redness that does not go away when pressure is applied and is a sign that structural damage has occurred to the skin

Question 28

methods for measuring wound size

Answer 28

1. tracing wound circumference

2. measuring length and width of the wound

Question 29

acute wounds

Answer 29

develop as a result of injury and typically are a result of trauma

Question 30

chronic wounds

Answer 30

develop over time from acute wounds that do not progress in healing

Question 31

surgical debridement

Answer 31

• accumulated debris and dead tissue are removed with a scalpel or scissors
• debridement decreases the number of bacteria in the wound and stimulates the rebuilding of the wound bed by contraction and epithelialization

Question 32

major complications of wounds are

Answer 32

infections 
dehiscences- wound comes apart
evisceration- even further process
hematomas/seromas
fistulas- different layers connect in the wrong spot