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Skin & Wound Care questions and answers
Skin & Wound Care questions and answers A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure ulcer? a) Use pillows to maintain a side-lying position as needed. b) Elevate the head of the bed 90 degrees. c) Place a foot board on the bed. d) Provide incontinent care every 4 hours as needed. - Use pillows to maintain a side-lying posi...
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Skin & Wound Care questions and answers
Skin & Wound Care questions and answers What are the 3 layers that the skin is made up of? - Epidermis, dermis, and hypodermis What is impaired skin and tissue integrity? - Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament What're some risk factors of impaired skin and tissue integrity? - - Impaired circulation and oxygenation - impaired immune function - diabetes - inadequate nutrition - ob...
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Skin & Wound Care questions and answers
Skin & Wound Care questions and answers Acute Wound A type of cut, scrape, or injury that happens suddenly, like when you accidentally cut your finger, scrape your knee, or get a paper cut. These wounds usually heal quickly, like in a few days or weeks, as long as they're kept clean and treated properly. Cascade When one reaction in the body sets off a chain of other reactions, like falling dominoes. For example, if you get a cut, your body starts a healing cascade. Clotting a...
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skin & wound care questions and answers
skin & wound care questions and answers A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development? a. Decreased level of consciousness b. Adequate dietary intake c. Shortness of breath d. Muscular pain A. Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure b...
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SKIN/WOUND CARE questions and answers
SKIN/WOUND CARE questions and answers What is the name of baby acne - milia What is the name for women who grow excessive amounts of hair? - Hirsutism Birthmarks are a result of what? - Hyperpigmentation Moles are the result of raised what? - Cluster of melanocytes What is senile purpura? - when vascular fragility results in easy bruising; common among elderly What does a Mongolian spot look like? - A bruise like spot (on the coxyx of babies sometimes) wavy, irregular borders, mela...
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SKIN/WOUND CARE questions and answers
SKIN/WOUND CARE questions and answers Erythema - Redness in lightly pigmented skin Abscess - A collection of infected fluid that has not drained Epithelialization - Process where epithelial cells form a new surface layer Dressing - Protective covering placed over a wound Hematoma - Localized mass of usually clotted blood
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SKIN/WOUND CARE questions and answers
SKIN/WOUND CARE questions and answers Subjective Data previous skin disease, recent change in pigmentation, sunburn history, age, change in moles, excessive dryness/mosture, pruritic, bruising, rash/lesion, hair loss, change in nails Risk for skin breakdown related to chronic disease: DM- poor wound healing / PVD-poor circulation Subjective Data- Personal Behavior meds (do they have skin side effects), smoking, activity, skin care habits (sunscreen), nutrition and fluid intake, l...
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SKIN + wound care questions and answers
SKIN + wound care questions and answers Lesion Single area of altered skin Rash Widespread eruption of flesions Erythema/erythematous Redness due to dilated blood vessels that bland when pressed (turns white when you let go) Pigmentation Any shade of brown, black, grey or blue resulting from presence of melanin at different depth in skin Hyperpigmentation Excessive colour in skin causing it to be darker than normal Hypopigmentation LOSS of melanin causing skin to be paler...
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Skin/Wound Care questions and answers
Skin/Wound Care questions and answers Approximated Friction - Removal of dead tissue Blanching - A moist-heat method of cooking turning white debridement - Removal of dirt induration - abnormal hard spots Dehiscence - A separation of layers, usually of a surgical incision Epithelialization - The process of renewal of a new surface layer of epithelium
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Skin/Wound Care questions and answers
Skin/Wound Care questions and answers T/F. When doing a lower extremity assessment, it is only necessary to evaluate the involved extremity. - False It is necessary to check bilateral extremities; comparing one to the other. T/F. In assessment of arterial disease, it is important to rule out coexisting edema. If edema is present, management may include elevation, pneumatic compression device or mild layered compression wraps depending on severity of LEAD. - True
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Skin/Wound Care questions and answers
Skin/Wound Care questions and answers Describe the skin. (why is important, and what does it do?) - Largest organ; joins mucous membranes to act as a shield - Must maintain a cellular fluid balance to be able to fluctuate with changing body, providing constant blood flow to maintain integrity, tensile strength in the dermis and epidermis - Provides biofeedback system for thermoregulation in times of stress during environmental change - Contains constant interaction with hormone regulating sy...
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Skin & Wound Care questions and answers
Skin & Wound Care questions and answers When the body's internal environment is open to microorganisms that may be harmful, what happens to the skin? - it's integrity (intactness) is broken Any abnormal opening or break in the skin - Wound A wound is described as a physical injury causing a break in the skin or mucous membrane. What are 3 of the most common types of wounds? - (1) trauma wounds (accidental or self inflicted) (2) surgical incisions (3) several types of ulcers
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Skin & Wound Care questions and answers
Skin & Wound Care questions and answers Stages of wound - - Inflammatory phase - pro-life phase - Maturation Healing Process - - primary intention - secondary intention - third intention Assessment of Wounds - - access color • red - healthy regeneration = covered wound • yellow - healthy drainage = clean wound • Black - eschar = debride wound Access size of wound - - length , width , depth
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Skin/wound care questions and answers
Skin/wound care questions and answers Pressure ulcer prevention - Assess at risk PT daily - Cleanse the skin routinely - Maintain higher humidity, use moisturizers - Protect skin from moisture - Minimize skin injury from friction or shearing - Turning every 2 hours - Support surfaces/devices (air flow mattress) - Nutritional supplements - Improve mobility The standard frequency with which we should offer to turn/assist in repositioning a patient every 2 hours Expected finding for a norma...
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skin/wound care questions and answers
skin/wound care questions and answers What is a pressure injury? - -localized damage to the skin or underlying tissue resulting from prolonged pressure and/or friction to the skin, predominantly occurring over a bony prominence Why is it important to have a committee that standardizes how we assess document and identifying wounds? - NPUAP (a pressure injury organization) -for consistency (everything needs to be the same for hospital the hospital) Who is at risk for a pressure injury? -...
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Skin & Wound Care questions and answers
Skin & Wound Care questions and answers Functions of Skin - -Provides for identifying characteristics(including heredity, racial, dietary and emotional considerations) Physiologic functions - protects underlying structures (absorbing, cushioning, restricting) - serves as heat-regulating mechanism (thermoregulation) - serves as sense organ - involved in metabolism of salt and water - stores fat - facilitates gas exchange - converts sunlight into Vitamin D - provides homeostatic environm...
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Skin Integrity & Wound Care questions and answers
Skin Integrity & Wound Care questions and answers The nurse determines that the client's wound may be infected. To perform an aerobic wound culture, the nurse should: 1. Collect the superficial drainage 2. Collect the culture before cleansing the wound 3. Obtain a culturette tube and use sterile technique 4. Use the same technique as for collecting an anaerobic culture - ANS: 3 The nurse uses different methods of specimen collection for aerobic or anaerobic organisms. To col...
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Skin Integrity and Wound Care questions and answers
Skin Integrity and Wound Care questions and answers Fine sutures cause minimal tissue injury. The finer the sutures, the more minimal the tissue injury. Deep sutures are composed of an absorbable, not nonabsorbable, material that disappears over time. All sutures are foreign bodies, and so they can all cause local inflammation. Retention sutures are placed more deeply than skin sutures. - Which statement is true regarding sutures? 1 Fine sutures cause minimal tissue injury. 2 ...
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Skin Integrity and Wound Care questions and answers
Skin Integrity and Wound Care questions and answers What is a pressure injury? - localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device What are other terms that have been used in the past for a pressure injury? - pressure sore, pressure ulcer, decubitus ulcer, or bedsore What is the description of a Stage 1 pressure injury? - Intact skin with a localized area of nonblanchable erythema, which may appear differe...
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Skin Integrity and Wound Care questions and answers
Skin Integrity and Wound Care questions and answers What does the Braden Scale evaluate? Skin integrity @ bony prominences, including any wounds Risk factors that place pt @ risk for skin breakdown The amount of repositioning pt can tolerate The factors that place pt at risk for poor healing - Risk factors that place pt @ risk for skin breakdown 3 pressure-related factors contribute to pressure ulcer development: - (1) pressure intensity, (2) pressure duration, (3) tissue t...
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