Skin Integrity and Wound Care (Exam 3) Nursing Study Guide & Exam Review
SKIN INTEGRITY AND WOUND CARE (EXAM 3)
Skin integrity and Wound Care
# Term Definition
1 Skin largest organ of body 1st line of defense
synthesizes Vit D, thermoreceptor, protects
against microbial infections
2 Dermal-Epithelial Junction Separates the Dermis and Epidermis
3 Epidermis Top layer of skin Prevents foreign objects from
penetrating body
4 Dermis Inner layer of skin Gives structure and flexibility
to skin supplies nutrients, removes wastes
senses pain, touch, pressure, and temperature
5 Pressure Ulcer pressure sore, decubitus sore, bed sore.
6 Factors for Pressure Ulcer/Bed pressure intensity: How much weight/gravity is
sores put on skin Blanching Pressure Duration Tissue
Tolerance
7 Risk Factors for Pressure Ulcer Impaired sensory perception:clients dont know
Development they need to move to shift pressure Impaired
Mobility: parapelegic,immobile,hemoplegic Shear
(shifting of skin) Friction Moisture Alterations in
LOC
8 Stage 1 Pressure Ulcer Formation 1: intact skin, NONBLANCHABLE, erythema not
painful
9 stage 2 Pressure Ulcer Formation partial-thickness skin loss INVOLVES EPIDERMIS,
DERMIS OR BOTH blister,abrasion,shallow crater
blood filled, boggy, no blanching
10 Stage 3 Bed Sores full thickness skin loss: involving damage or
necrosis to SUBCUTANEOUS TISSUES possible
tunneling and pain
11 Stage 4 full thickness skin loss with tissue necrosis or
damage to MUSCLE,BONE OR SUPPORTING
STRUCTURES possibly showing bone, and
tunneling
, Skin Integrity and Wound Care (Exam 3) Nursing Study Guide & Exam Review
SKIN INTEGRITY AND WOUND CARE (EXAM 3)
# Term Definition
12 Wound Classification: acute and acute: timely and orderly healing: wound edges
chronic are clean and intact: surgery and trauma
Chronic: fails to heal in an orderly and timely
process: diabetes,elderly, cardiovascular
compromise, chronic inflammation
13 Phases of wound healing (4) 1. Hemostasis phase 2. Inflammatory phase 3.
Proliferative phase 4. Remodeling or proliferation
phase
14 Hemostasis phase control of bleeding, clots form, injured blood
vessels constrict, platelets accumulate
15 Inflammatory phase acute= 3-4 days, chronic= longer bringing in WBC
and healing cells debris phagocytosed
16 Phases of healing 1. Hemostasis phase 2. Inflammatory phase 3.
Proliferative phase 4. Remodeling or proliferation
phase HIPR: Hot Italians Practice Religion
17 Tell-tale signs of inflammatory erythema, edema, pain, warmth WEPE Women
phase Enjoy Perfect Evenings
18 Proliferative phase: develops? 4-21 days; collagen produced; development of
produces? tensile strength and scar tissue; granulation
tissue formation; epithelialization (new skin); new
blood vessels form
19 Remodeling/ Maturation Phase: 3-4 weeks; fibroblasts leave wound, can last for
what leaves the wound? lasts for..? over a year. new and remodeled collagen is
what is deposited? deposited; tightens and reduces scar size; tensile
strength increases (regains 80% strength)--->
scar
20 Types of Wound Healing Primary, Secondary and Tertiary
21 Primary wound healing what kind tissue surfaces closed low infection risk healing is
of wounds? risk for infection? quick with minimal scar formation ex: smooth
surgical wound, edges come together nicely,
well-approximated edges
SKIN INTEGRITY AND WOUND CARE (EXAM 3)
Skin integrity and Wound Care
# Term Definition
1 Skin largest organ of body 1st line of defense
synthesizes Vit D, thermoreceptor, protects
against microbial infections
2 Dermal-Epithelial Junction Separates the Dermis and Epidermis
3 Epidermis Top layer of skin Prevents foreign objects from
penetrating body
4 Dermis Inner layer of skin Gives structure and flexibility
to skin supplies nutrients, removes wastes
senses pain, touch, pressure, and temperature
5 Pressure Ulcer pressure sore, decubitus sore, bed sore.
6 Factors for Pressure Ulcer/Bed pressure intensity: How much weight/gravity is
sores put on skin Blanching Pressure Duration Tissue
Tolerance
7 Risk Factors for Pressure Ulcer Impaired sensory perception:clients dont know
Development they need to move to shift pressure Impaired
Mobility: parapelegic,immobile,hemoplegic Shear
(shifting of skin) Friction Moisture Alterations in
LOC
8 Stage 1 Pressure Ulcer Formation 1: intact skin, NONBLANCHABLE, erythema not
painful
9 stage 2 Pressure Ulcer Formation partial-thickness skin loss INVOLVES EPIDERMIS,
DERMIS OR BOTH blister,abrasion,shallow crater
blood filled, boggy, no blanching
10 Stage 3 Bed Sores full thickness skin loss: involving damage or
necrosis to SUBCUTANEOUS TISSUES possible
tunneling and pain
11 Stage 4 full thickness skin loss with tissue necrosis or
damage to MUSCLE,BONE OR SUPPORTING
STRUCTURES possibly showing bone, and
tunneling
, Skin Integrity and Wound Care (Exam 3) Nursing Study Guide & Exam Review
SKIN INTEGRITY AND WOUND CARE (EXAM 3)
# Term Definition
12 Wound Classification: acute and acute: timely and orderly healing: wound edges
chronic are clean and intact: surgery and trauma
Chronic: fails to heal in an orderly and timely
process: diabetes,elderly, cardiovascular
compromise, chronic inflammation
13 Phases of wound healing (4) 1. Hemostasis phase 2. Inflammatory phase 3.
Proliferative phase 4. Remodeling or proliferation
phase
14 Hemostasis phase control of bleeding, clots form, injured blood
vessels constrict, platelets accumulate
15 Inflammatory phase acute= 3-4 days, chronic= longer bringing in WBC
and healing cells debris phagocytosed
16 Phases of healing 1. Hemostasis phase 2. Inflammatory phase 3.
Proliferative phase 4. Remodeling or proliferation
phase HIPR: Hot Italians Practice Religion
17 Tell-tale signs of inflammatory erythema, edema, pain, warmth WEPE Women
phase Enjoy Perfect Evenings
18 Proliferative phase: develops? 4-21 days; collagen produced; development of
produces? tensile strength and scar tissue; granulation
tissue formation; epithelialization (new skin); new
blood vessels form
19 Remodeling/ Maturation Phase: 3-4 weeks; fibroblasts leave wound, can last for
what leaves the wound? lasts for..? over a year. new and remodeled collagen is
what is deposited? deposited; tightens and reduces scar size; tensile
strength increases (regains 80% strength)--->
scar
20 Types of Wound Healing Primary, Secondary and Tertiary
21 Primary wound healing what kind tissue surfaces closed low infection risk healing is
of wounds? risk for infection? quick with minimal scar formation ex: smooth
surgical wound, edges come together nicely,
well-approximated edges
