CCBC Nursing 153- Exam 2 Prep
Study Set
What are the 5 functions of the skin? - Answer **Think PTSSD**
1. Protection (1st line of defense)
2. Thermoregulation
3. Sensation (heat, cold, pressure, pain, contact)
4. Secretion/Excretion
5. Vitamin D formation
What are 9 factors that affect skin integrity? - Answer 1. Age
2. Mobility
3. Moisture of the skin
4. Nutrition and Hydration
5. Diminished Sensation or Cognition (ex, a diabetic patient who doesn't understand the
disease process)
6. Impaired Circulation
7. Fever
8. Lifestyle
9. Medications
When it comes to skin integrity, any break in the skin can lead to infection. What are the
2 focuses of the nurse regarding the skin? - Answer 1. Protecting the skin.
2. Maintaining skin integrity.
What are the 3 factors that can cause a break in skin integrity? - Answer 1. Traumatic
injuries.
2. Surgery.
3. Pressure.
What are the 3 layers that make up normal skin? - Answer 1. Epidermis: top layer,
,avascular, receives nutrition from the dermis, epithelial cells on this layer are constantly
being replaced to protect against pathogens.
2. Dermis: 2nd layer, provides strength and mechanical support.
3. Subcutaneous Fat Layer: fatty tissue that provides cushioning.
When performing a skin assessment, what are the 9 factors that should be evaluated? -
Answer 1. Color: pallor, erythema (redness), jaundice, cyanosis.
2. Temperature: Warm or Cold.
3. Moisture
4. Odor
5. Turgor
6. Vascularity
7. Edema
8. Lesions
9. Texture/thickness
There are two types of wounds in regards to skin INTEGRITY, what are they? - Answer 1.
Closed wound: when the epidermis and dermis remain intact. Ex, a bruise or contusion.
2. Open wound: when there is a break in the skin or mucous membrane.
What are 3 types of open wounds? Give examples of each. - Answer 1. Laceration: a
tearing injury, usually with irregular wound edges. These wounds are usually
contaminated with debris, dirt, or bacteria. Ex, a scratch.
2. Abrasion: SUPERFICIAL, involves the scraping or rubbing of superficial layers of the
skin. Ex, a skinned knee.
3. Puncture: a PENETRATING injury due to a pointed object without a blade; depth is
greater than length. Ex, an ice pick puncture wound.
In regards to skin integrity, what is the term used to describe a closed, intentional
surgical incision? - Answer An APPROXIMATED incision
In regards to the HEALING TIME of a wound, what are the two types of wounds? -
Answer 1. Acute Wound: this wound heals on its own over a short duration, proceeds
through an orderly and timely reparative process, and in a healthy person it usually
heals w/o complications. This wound can be a result of trauma or a surgical incision.
2. Chronic Wound: this wound takes a lonngggg time to heal and usually exceeds the
expected length of recovery. It fails to proceed through an orderly and timely reparative
,process, and healing is usually interrupted due to infection, continued trauma,
ischemia, or edema. Ex, pressure, arterial, venous, and diabetic ulcers.
In regards to WOUND CONTAMINATION, what are the 3 types of wounds? - Answer 1.
Clean: UNCONTAMINATED. This wound contains no pathogenic organisms and does not
include areas going into the GI, GU, respiratory, or oral-pharyngeal cavities.
2. Clean Contaminated: a wound made under ASEPTIC CONDITIONS, but involving a
body cavity that normally harbors microorganisms so it DOES include the GI, GU,
respiratory, and oral-pharyngeal cavities.
3. Contaminated: involves a MAJOR BREAK in aseptic technique; open traumatic
wounds not under controlled conditions. Ex, spillage from GI tract or a ruptured
appendix.
In regards to the DEPTH of wounds, what are the two types? - Answer 1.
Partial-thickness: wounds that are SHALLOW, involving loss of the epidermis and
possibly partial loss of the dermis. This wound type heals be REGENERATION. Ex, Stage
II wounds.
2. Full-thickness: wounds that extend into the DERMIS and into deeper tissues
(subcutaneous fat and muscle). This wound type heals by SCAR FORMATION because
deep skin structures do not regenerate.
What are the 3 different PROCESSES of wound healing? - Answer 1. Primary Intention:
skin edges are approximated or CLOSED. This is usually when a patient had surgery and
the wounds were intentionally created in an operating room.
2. Secondary Intention: skin layer are NOT close or approximated. This wound is left
open until SCAR TISSUE or granulated tissue forms. If there is a large gaping wound
that is being PACKED, the wound is healing by secondary intention.
3. Tertiary Intention: healing occurs when a wound is closed at a later time after the
wound surfaces have already started to granulate. This is used when wounds are deep
or until there are no more signs of infection. Whenever a wound is left open for a long
period of time TO DRAIN, the wound is healing by tertiary intention.
The wound repair process is different for partial-thickness and full-thickness wounds.
What are the 2 stages of the wound repair process for partial-thickness wounds, such
as a Stage II pressure ulcer? - Answer 1. Inflammatory Response: this is generally
limited to the first 24 hours and involves redness, swelling, and a moderate amount of
serous exudate.
2. Proliferation (reproduction) and Migration: epithelial cells begin to reproduce and
migrate across the wound bed soon after the wound occurs. Wounds left open to the air
resurface in 6-7 days. **Wounds kept moist resurface in only 4 days because epithelial
cells migrate better across a moist surface**
The wound repair process is different for partial-thickness and full-thickness wounds.
, What are the 4 stages of the wound repair process for full-thickness wounds, such as
Stage III and Stage IV pressure ulcers? - Answer 1. Homeostasis: the body's natural
response to trauma. Injured blood vessels constrict, platelets stop the bleeding, and
clots form a fibrin matrix.
2. Inflammatory Phase: begins 3 minutes after injury and last up to 3 DAYS. Damaged
tissue and mast cells secrete histamine, resulting in the vasodilation of capillaries and
WBC's go to the damaged tissue.
3. Proliferation (Reproductive) Phase: begins and lasts 3-24 DAYS. Granulation tissue is
produced to fill and resurface the wound with new skin.
4. Remodeling (Maturation) Phase: final stage of the healing process and can take UP
TO A YEAR. The collagen scar continues to gain strength, but the healed wound does
not have the strength of the original tissue.
The Inflammatory Phase of the wound healing process results in exudate or wound
drainage. Exudate is made up of fluid and cells that escape from the blood vessels and
are deposited in wound drainage. When assessing drainage it's important to note the
amount, color, consistency, and odor. What would excessive exudate be an indication
of? - Answer The presence of an infection.
What are the 3 functions of wound drainage? - Answer 1. Dilution of Toxins: produced by
bacteria and dying cells.
2. Transportation: this includes leukocytes, plasma proteins, and antibodies to the site.
3. Removal away from the site: this includes bacterial toxins, dead cells, and debris.
What are the 4 different type of wound drainage? - Answer 1. Serous: clear, watery
plasma.
2. Serosanguineous: drainage is a mixture of serous and some blood tinged, seen with
surgical incisions. Pale, pink, watery mixture of clear and red fluid.
3. Sanguineous: indication of capillary damage; large number of RBC's, severe
inflammation. This drainage is bright red and indicates active bleeding. Will also see
clotting.
4. Purulent (Pus): indication of severe inflammation WITH INFECTION. Contains
leukocytes, liquified dead cells, dead and living bacteria. This drainage is thick, yellow,
green, tan or brown.
Drains are special equipment that pull drainage away from a surgical area when a
wound has been closed. What are the 3 types of drains? - Answer 1. Jackson-Pratt or
J.P. Drain: closed suction drainage system that should be emptied when half full.
2. Hemovac: closed suction drainage system.
Study Set
What are the 5 functions of the skin? - Answer **Think PTSSD**
1. Protection (1st line of defense)
2. Thermoregulation
3. Sensation (heat, cold, pressure, pain, contact)
4. Secretion/Excretion
5. Vitamin D formation
What are 9 factors that affect skin integrity? - Answer 1. Age
2. Mobility
3. Moisture of the skin
4. Nutrition and Hydration
5. Diminished Sensation or Cognition (ex, a diabetic patient who doesn't understand the
disease process)
6. Impaired Circulation
7. Fever
8. Lifestyle
9. Medications
When it comes to skin integrity, any break in the skin can lead to infection. What are the
2 focuses of the nurse regarding the skin? - Answer 1. Protecting the skin.
2. Maintaining skin integrity.
What are the 3 factors that can cause a break in skin integrity? - Answer 1. Traumatic
injuries.
2. Surgery.
3. Pressure.
What are the 3 layers that make up normal skin? - Answer 1. Epidermis: top layer,
,avascular, receives nutrition from the dermis, epithelial cells on this layer are constantly
being replaced to protect against pathogens.
2. Dermis: 2nd layer, provides strength and mechanical support.
3. Subcutaneous Fat Layer: fatty tissue that provides cushioning.
When performing a skin assessment, what are the 9 factors that should be evaluated? -
Answer 1. Color: pallor, erythema (redness), jaundice, cyanosis.
2. Temperature: Warm or Cold.
3. Moisture
4. Odor
5. Turgor
6. Vascularity
7. Edema
8. Lesions
9. Texture/thickness
There are two types of wounds in regards to skin INTEGRITY, what are they? - Answer 1.
Closed wound: when the epidermis and dermis remain intact. Ex, a bruise or contusion.
2. Open wound: when there is a break in the skin or mucous membrane.
What are 3 types of open wounds? Give examples of each. - Answer 1. Laceration: a
tearing injury, usually with irregular wound edges. These wounds are usually
contaminated with debris, dirt, or bacteria. Ex, a scratch.
2. Abrasion: SUPERFICIAL, involves the scraping or rubbing of superficial layers of the
skin. Ex, a skinned knee.
3. Puncture: a PENETRATING injury due to a pointed object without a blade; depth is
greater than length. Ex, an ice pick puncture wound.
In regards to skin integrity, what is the term used to describe a closed, intentional
surgical incision? - Answer An APPROXIMATED incision
In regards to the HEALING TIME of a wound, what are the two types of wounds? -
Answer 1. Acute Wound: this wound heals on its own over a short duration, proceeds
through an orderly and timely reparative process, and in a healthy person it usually
heals w/o complications. This wound can be a result of trauma or a surgical incision.
2. Chronic Wound: this wound takes a lonngggg time to heal and usually exceeds the
expected length of recovery. It fails to proceed through an orderly and timely reparative
,process, and healing is usually interrupted due to infection, continued trauma,
ischemia, or edema. Ex, pressure, arterial, venous, and diabetic ulcers.
In regards to WOUND CONTAMINATION, what are the 3 types of wounds? - Answer 1.
Clean: UNCONTAMINATED. This wound contains no pathogenic organisms and does not
include areas going into the GI, GU, respiratory, or oral-pharyngeal cavities.
2. Clean Contaminated: a wound made under ASEPTIC CONDITIONS, but involving a
body cavity that normally harbors microorganisms so it DOES include the GI, GU,
respiratory, and oral-pharyngeal cavities.
3. Contaminated: involves a MAJOR BREAK in aseptic technique; open traumatic
wounds not under controlled conditions. Ex, spillage from GI tract or a ruptured
appendix.
In regards to the DEPTH of wounds, what are the two types? - Answer 1.
Partial-thickness: wounds that are SHALLOW, involving loss of the epidermis and
possibly partial loss of the dermis. This wound type heals be REGENERATION. Ex, Stage
II wounds.
2. Full-thickness: wounds that extend into the DERMIS and into deeper tissues
(subcutaneous fat and muscle). This wound type heals by SCAR FORMATION because
deep skin structures do not regenerate.
What are the 3 different PROCESSES of wound healing? - Answer 1. Primary Intention:
skin edges are approximated or CLOSED. This is usually when a patient had surgery and
the wounds were intentionally created in an operating room.
2. Secondary Intention: skin layer are NOT close or approximated. This wound is left
open until SCAR TISSUE or granulated tissue forms. If there is a large gaping wound
that is being PACKED, the wound is healing by secondary intention.
3. Tertiary Intention: healing occurs when a wound is closed at a later time after the
wound surfaces have already started to granulate. This is used when wounds are deep
or until there are no more signs of infection. Whenever a wound is left open for a long
period of time TO DRAIN, the wound is healing by tertiary intention.
The wound repair process is different for partial-thickness and full-thickness wounds.
What are the 2 stages of the wound repair process for partial-thickness wounds, such
as a Stage II pressure ulcer? - Answer 1. Inflammatory Response: this is generally
limited to the first 24 hours and involves redness, swelling, and a moderate amount of
serous exudate.
2. Proliferation (reproduction) and Migration: epithelial cells begin to reproduce and
migrate across the wound bed soon after the wound occurs. Wounds left open to the air
resurface in 6-7 days. **Wounds kept moist resurface in only 4 days because epithelial
cells migrate better across a moist surface**
The wound repair process is different for partial-thickness and full-thickness wounds.
, What are the 4 stages of the wound repair process for full-thickness wounds, such as
Stage III and Stage IV pressure ulcers? - Answer 1. Homeostasis: the body's natural
response to trauma. Injured blood vessels constrict, platelets stop the bleeding, and
clots form a fibrin matrix.
2. Inflammatory Phase: begins 3 minutes after injury and last up to 3 DAYS. Damaged
tissue and mast cells secrete histamine, resulting in the vasodilation of capillaries and
WBC's go to the damaged tissue.
3. Proliferation (Reproductive) Phase: begins and lasts 3-24 DAYS. Granulation tissue is
produced to fill and resurface the wound with new skin.
4. Remodeling (Maturation) Phase: final stage of the healing process and can take UP
TO A YEAR. The collagen scar continues to gain strength, but the healed wound does
not have the strength of the original tissue.
The Inflammatory Phase of the wound healing process results in exudate or wound
drainage. Exudate is made up of fluid and cells that escape from the blood vessels and
are deposited in wound drainage. When assessing drainage it's important to note the
amount, color, consistency, and odor. What would excessive exudate be an indication
of? - Answer The presence of an infection.
What are the 3 functions of wound drainage? - Answer 1. Dilution of Toxins: produced by
bacteria and dying cells.
2. Transportation: this includes leukocytes, plasma proteins, and antibodies to the site.
3. Removal away from the site: this includes bacterial toxins, dead cells, and debris.
What are the 4 different type of wound drainage? - Answer 1. Serous: clear, watery
plasma.
2. Serosanguineous: drainage is a mixture of serous and some blood tinged, seen with
surgical incisions. Pale, pink, watery mixture of clear and red fluid.
3. Sanguineous: indication of capillary damage; large number of RBC's, severe
inflammation. This drainage is bright red and indicates active bleeding. Will also see
clotting.
4. Purulent (Pus): indication of severe inflammation WITH INFECTION. Contains
leukocytes, liquified dead cells, dead and living bacteria. This drainage is thick, yellow,
green, tan or brown.
Drains are special equipment that pull drainage away from a surgical area when a
wound has been closed. What are the 3 types of drains? - Answer 1. Jackson-Pratt or
J.P. Drain: closed suction drainage system that should be emptied when half full.
2. Hemovac: closed suction drainage system.
