Theory Exam 2 (Skin Integrity and
wound care) exam
dehiscence - ANS separation of the layers of a surgical wound; may be partial, superficial, or a
complete disruption of the surgical wound
erythema - ANS redness of the skin
evisceration - ANS protrusion of viscera through an incision
exudate - ANS fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and
white blood cells
eschar - ANS thick, leathery scab or dry crust that is necrotic and must be removed for adequate
healing to occur
debridement - ANS cleaning away devitalized tissue and foreign matter from a wound
fistula - ANS an abnormal passage from an internal organ to the skin or from one internal organ to
another
hematoma - ANS localized mass of usually clotted blood
ischemia - ANS deficiency of blood in a particular area
maceration - ANS softening through liquid; overhydration
Pressure drainage - ANS death of cells and tissue
Skin (essential for maintaining life) - ANS What is the largest organ in the body?
Skin, subcutaneous layer, and appendages of the skin - ANS What is the integumentary made up of?
,epidermis & dermis - ANS What are the 2 layers of the skin?
·protection-barrier
temperature regulation- compensates for both heat and cold
psychosocial- external appearance
sensation- touch, pain, pressure, temperature
vitamin D production-activated by ultraviolet rays from the sun
immunologic-triggered when the skin is broken
absorption- medications
elimination-sweat (water, electrolytes, and nitrogenous wastes) - ANS What are the functions of the
skin?
Fragile, high risk for injury and infection. - ANS Developmental considerations affecting skin integrity:
Infants
Becomes increasingly resistant to injury and infection. Develop immunology - ANS Developmental
considerations affecting skin integrity:
Child
easily damaged - ANS Developmental considerations affecting skin integrity:
Older adult
,•Increased risk for injury.
•Less capacity to insulate.
•Sensation of pressure and pain is reduced - ANS Older Adult:
•Subcutaneous and dermal tissues become thin.
•Skin is dryer and itching may occur - ANS Older Adult:
Activity of the sebaceous and sweat glands decreases.
Prolonged healing time - ANS Older Adult:
Cell renewal is decreased.
This causes?
lose elasticity. - ANS Older Adult:
Collagen fiber is less organized, so it causes skin to?
Age
lifestyle variables
changes in health state
illness
Diagnostic measures
therapeutic measures - ANS Factors that place a person at risk for skin alteration
Skin loses elasticity and becomes prone to breakdown - ANS Dehydration and malnutrition: If fluid,
protein and vitamin C is deficient...
, Then what occurs?
injury - ANS Reduced sensation (paralysis, nerve damage):If patient has an inability to sense
temperature extremes, pressure, and friction...
•Then what is he/she at an increased risk for?
It will become compromised and breakdown. Placing the patient at increased risk for injury. - ANS
The nurse correctly identifies if this patient does not receive adequate nutrition what will most likely
happen to the integumentary system?
older adults - ANS Who is at high risk for pressure ulcers?
high protein diets - ANS What type of diet promotes healing?
Diabetic Ulcer (chronic condition) - ANS •Cuts and sores that do not heal.
•Lesions on the lower extremities that ulcerate and become necrotic.
•Recurrent bacterial and fungal infections.
-They have comprised skin integrity due to instability with blood glucose levels- vascular problems
increases delayed healing - ANS What compromises individuals with diabetes?
Hyperglycemia because it causes more damage; it slows and delays wound healing - ANS Is a patient
more opt to get a foot ulcer when they are hyper or hypoglycemia?
skin breakdown - ANS Patients on bed rest have increased risk for ___________
irritant - ANS Casts are an ______ to the skin
Medications - ANS May cause:
wound care) exam
dehiscence - ANS separation of the layers of a surgical wound; may be partial, superficial, or a
complete disruption of the surgical wound
erythema - ANS redness of the skin
evisceration - ANS protrusion of viscera through an incision
exudate - ANS fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and
white blood cells
eschar - ANS thick, leathery scab or dry crust that is necrotic and must be removed for adequate
healing to occur
debridement - ANS cleaning away devitalized tissue and foreign matter from a wound
fistula - ANS an abnormal passage from an internal organ to the skin or from one internal organ to
another
hematoma - ANS localized mass of usually clotted blood
ischemia - ANS deficiency of blood in a particular area
maceration - ANS softening through liquid; overhydration
Pressure drainage - ANS death of cells and tissue
Skin (essential for maintaining life) - ANS What is the largest organ in the body?
Skin, subcutaneous layer, and appendages of the skin - ANS What is the integumentary made up of?
,epidermis & dermis - ANS What are the 2 layers of the skin?
·protection-barrier
temperature regulation- compensates for both heat and cold
psychosocial- external appearance
sensation- touch, pain, pressure, temperature
vitamin D production-activated by ultraviolet rays from the sun
immunologic-triggered when the skin is broken
absorption- medications
elimination-sweat (water, electrolytes, and nitrogenous wastes) - ANS What are the functions of the
skin?
Fragile, high risk for injury and infection. - ANS Developmental considerations affecting skin integrity:
Infants
Becomes increasingly resistant to injury and infection. Develop immunology - ANS Developmental
considerations affecting skin integrity:
Child
easily damaged - ANS Developmental considerations affecting skin integrity:
Older adult
,•Increased risk for injury.
•Less capacity to insulate.
•Sensation of pressure and pain is reduced - ANS Older Adult:
•Subcutaneous and dermal tissues become thin.
•Skin is dryer and itching may occur - ANS Older Adult:
Activity of the sebaceous and sweat glands decreases.
Prolonged healing time - ANS Older Adult:
Cell renewal is decreased.
This causes?
lose elasticity. - ANS Older Adult:
Collagen fiber is less organized, so it causes skin to?
Age
lifestyle variables
changes in health state
illness
Diagnostic measures
therapeutic measures - ANS Factors that place a person at risk for skin alteration
Skin loses elasticity and becomes prone to breakdown - ANS Dehydration and malnutrition: If fluid,
protein and vitamin C is deficient...
, Then what occurs?
injury - ANS Reduced sensation (paralysis, nerve damage):If patient has an inability to sense
temperature extremes, pressure, and friction...
•Then what is he/she at an increased risk for?
It will become compromised and breakdown. Placing the patient at increased risk for injury. - ANS
The nurse correctly identifies if this patient does not receive adequate nutrition what will most likely
happen to the integumentary system?
older adults - ANS Who is at high risk for pressure ulcers?
high protein diets - ANS What type of diet promotes healing?
Diabetic Ulcer (chronic condition) - ANS •Cuts and sores that do not heal.
•Lesions on the lower extremities that ulcerate and become necrotic.
•Recurrent bacterial and fungal infections.
-They have comprised skin integrity due to instability with blood glucose levels- vascular problems
increases delayed healing - ANS What compromises individuals with diabetes?
Hyperglycemia because it causes more damage; it slows and delays wound healing - ANS Is a patient
more opt to get a foot ulcer when they are hyper or hypoglycemia?
skin breakdown - ANS Patients on bed rest have increased risk for ___________
irritant - ANS Casts are an ______ to the skin
Medications - ANS May cause:
