FPCC Skin Integrity and Wound Care (Exam 1) Multiple Choices Questions And Verified Answers Pass Guaranteed.

Why is skin integrity important? - correct answer primary defense; protective barrier (against infection); sensory organ; vitamin D synthesis how does a patient get "impaired skin integrity"? - correct answer healthcare providers cause it (ex. surgery); accidents, abrasions (animal bites, knives); circulatory problems (problems with arteries or venous circulation); too much pressure (pressure ulcers) by extent - correct answer wound assessment, classification; partial thickness (open), full thickness (open), closed by onset and duration - correct answer wound assessment, classification; acute (expected to heal quickly), chronic (not resolving quickly) by level of contamination - correct answer wound assessment, classification; clean (surgery), contaminated (puncture wounds, does NOT equal infected) by healing process - correct answer wound assessment, classification; primary -closed up(does not leave a lot of scarring), secondary - left open (scarring is a lot worse), tertiary - open then closed (not sutured immediately to be sure that it is clean) wound drainage assessment - correct answer amount, odor (if odor is present after being cleaned, might be infected), consistency (gel-like, water, sticky), color sanguineous drainage - correct answer bright red blood serosanguineous drainage - correct answer yellow with a little red surgical wounds assessment - correct answer incision (approximated edges, staples, sutures intact, surrounding tissue); presence of drains penrose - correct answer big plastic straw looking; inserted through puncture wound that the surgeon makes on purpose; does NOT come out of incision, but from a separate area jackson pratt (JP) - correct answer applies suction; can be measured in mL; can be measured without emptying hemovac - correct answer smushed down, stays smoothed and sucks out drainage abrasion - correct answer traumatic wound; only the top layer of skin is lost; partial thickness wound; most common drainage is serous or sero-sanguenous laceration - correct answer traumatic wound; patient cuts themselves on accident; can be partial/full thickness puncture wounds - correct answer traumatic wound; small, round, and sometimes deep holes healing of closed laceration - correct answer approximated edges, normal inflammation of healing (small swelling around incision as it heals), edges closing 7-10 days (when staples and sutures will come out) venous wound - correct answer brownish red, not too deep, fairly shallow, wound bed is beefy red; can have a lot of drainage; if not elevated, can be painful for the patient arterial wound - correct answer looks punched out, smooth borders, base of the wound is pale, most commonly seen on distal area of legs development of pressure ulcers - correct answer pressure duration/intensity, tissue tolerance (friction, shear, moisture, ability to redistribute pressure) pressure ulcer assessment - where - correct answer bony prominences, areas underweight, medical applianced (cast, bladder tube), damp areas, intertriginous (where the skin touches and rubs together) pressure ulcer assessment - what - correct answer color of skin (reactive hyperemia, blanching), warmth, edema, change in tissue consistency pressure ulcer assessment - when - correct answer on admission, daily, as needed based on assessment findings pressure ulcer assessment - by whom - correct answer pressure ulcer assessment should NOT be delegated; RN's are completely responsible for this assessment pressure ulcer assessment - how - correct answer braden scale who is more at risk for pressure ulcers? - correct answer decreased sensation, decreased mobility, medical devices, history of skin breakdown, poor nutrition stage I pressure ulcer - correct answer intact skin with nonblanchable redness stage II pressure ulcer - correct answer partial-thickness skin loss involving epidermis, dermis, or both stage III pressure ulcer - correct answer full-thickness tissue loss with visible fat stage IV pressure ulcer - correct answer full-thickness tissue loss with exposed bone, muscle, or tendon tunneling - correct answer a tunnel away from the primary wound and into the surrounding tissue; sinus tract: may end up in healthy surrounding tissue undermining - correct answer the skin is hanging over the wound; wound has gone under the wound and into healthy skin slough - correct answer yellow, looks like snot; attached and stringy; white tissue attached to the wound bed eschar - correct answer like dark black leather, necrotic dead tissue, often needs to be removed for a wound to heal (except on the heel) granulation - correct answer normal healthy, beefy red, will bleed easily deep tissue injury (DTI) - correct answer color, appearance, cause, bruising (echamotic) unstageable pressure ulcer - correct answer full thickness tissue loss, depth completely obscured by slough/eschar; stage III or IV when stages wound care expected outcomes - correct answer prevention, realistic time expectations for healing, the original staging of pressure ulcer remains; example: goal of wound improvement within a 2-week period - 50% increase in granulation tissue in the wound base, not further skin breakdown, an increase in the caloric intake by 10% nursing actions for decreased mobility/impaired sensation - correct answer reposition patient (involves taking their weight); avoid shear and friction (lift, don't drag); position patient properly; NEVER massage reddened or bony prominences nursing actions for moisture/incontinent of urine and/or feces - correct answer excellent hygiene care (do not soak feet of diabetics), assist in toiling on hourly rounds, absorbent pads only if necessary, apply moisture barriers after incontinence care; CONSIDER request for urinary or rectal tube nursing actions for impaired nutrition - correct answer collab with nutritionist; adequate calorie intake; promote positive nitrogen balance; ensure adequate hydration; adequate zinc, copper, and vitamins A and C; enteral or parenteral nutrition hemorrhage - correct answer wound complication; losing blood; can be external or internal infection - correct answer wound complication; prevention (use HH and the right dressing), early detection (most common wound appearance), lab (WBC and cultures), medications (analgesics, acetaminophen) dehiscence - correct answer complication of abdominal surgical wound; partial or total separation of wound layers; who - poor nutrition, coughing/vomiting; watch for bowel coming out of wound evisceration - correct answer complication of abdominal surgical wound; "pop!" sound; help patient lie down (low fowler's), sterile towels and sterile saline; NPO; monitor VS and hemorrhage cleaning a wound - correct answer normal saline or ordered cleanser; clean from least contaminated to the surrounding skin; use gentle friction only debridement - correct answer removing tissue so that the wound can actually heal; cutting out necrotic tissue so the wound can heal; sometimes it is done to be able to see the wound bed, like in unstageable pressure ulcers sharp debridement - correct answer physician or special nurse cuts away the tissue; can be done at bedside; quickest method but also the harshest (may be bumped up to sterile technique) mechanical debridement - correct answer done with gauze (wet to damp); pack gauze into wound, cover with secondary dressing, let dry, pull out gauze; DISADVANTAGE: pulling out healthy tissue enzymatic debridement - correct answer putting something with enzymes into the wound and then the enzymes break down protein and clean out wound; DANGER: do not put on surrounding tissue autolytic debridement - correct answer putting dressing in the wound, let sit; body starts breaking down the dressing and its body with its own chemicals; slow, but gentle biotherapy debridement - correct answer using sterile maggots to break down bad tissue; do not always stay in place purpose of wound dressings - correct answer moist environment for healing, absorb drainage, protect surrounding tissues, infection prevention, hemostasis, debridement, support or splint, aesthetics and comfort, insulation primary intention wound dressing - correct answer first change by provider, may reinforce, sterile asepsis, usually removed when drainage stops secondary intention wound dressing - correct answer based on staging or situation gauze/absorbant - correct answer wound dressing; great for a wound with a lot of drainage; can be used to deliver medication; packing used to keep healing from the bottom up non-adherent - correct answer wound dressing; "telfa"; prevents damage to healing tissue; allows drainage out transparent - correct answer wound dressing; used over IV's; barrier to external but allows O2 exchange; provides moist environment; partial thickness wounds (shallow wounds); change when moisture builds up hydrocolloid - correct answer wound dressing; waxy wafer looking (dualderm); won't stick well unless heat is applied (good for funny shaped wounds); maintains moist environment; don't use if wound dressing must be changed often hydrogel - correct answer wound dressing; does not adhere to skin; great for autolytic debridement, partial/full thickness wounds; covers the wound bed and cuts down on pain by eliminating nerve exposure; CHECK for seaweed allergies; requires secondary dressing alginates - correct answer very absorbent, check for seaweed allergies antimicrobials - correct answer check for iodine/shellfish allergies collagen - correct answer help promote wound healing and granulation; based on pig products/byproducts; check for religious or cultural stuff