Ch. 48 Skin Integrity and Wound Care (Exam #2 NR224) A Comprehensive Gide With Questions And Accurate Answers.

What are the two layers of the skin? - correct answer Epidermis Dermis Skin issues related to aging - correct answer Decreased elasticity Decreased collagen Thinning of muscles and tissues Medical conditions Polypharmacy Slower epithelialization and healing Decreased padding over bony prominences Prevention of skin-related issues in aging - correct answer Remove adhesive tape gently Use repositioning devices Assess bony prominences and risk areas Assess effects of medications What is a pressure ulcer? - correct answer Localized injury to skin/tissue as a result of pressure or pressure combined w/ shear or friction Risk factors for pressure ulcers - correct answer Decreased mobility Decreased sensory perception Incontinence Poor nutrition Altered level of consciousness Shear Friction Moisture Risk demographics for pressure ulcers - correct answer Older adults Spinal cord injury pts Trauma pts Fractured hip Long term care pts Acutely ill pts Diabetics Critical care pts How is a pressure ulcer formed? - correct answer Pressure -> decreased or obliterated blood flow -> tissue ischemia -> tissue death Blanchable hyperemia - correct answer Press finger over red (hyperemic) area Skin should blanch If hyperemia returns when finger is removed, body is trying to overcome ischemic episode Nonblanchable erythema - correct answer Erythematous area doesn't blanch Indicates possible deep tissue injury What can you do to detect blanchable hyperemia in darker skin? - correct answer Look for area that is darker than surrounding skin or a shiny hardened area Use bright light Assess changes in skin texture or temperature What are 3 factors that contribute to the pathogenesis of a pressure ulcer? - correct answer Pressure intensity Pressure duration Tissue tolerance What should you assess in order to classify a pressure ulcer? - correct answer Wound location Depth of tissue involvement Type and approximate percentatge of tissue in the wound bed Wound dimensions Exudate description Condition of surrounding skin Stage 1 Pressure Ulcer - correct answer Nonblanchable redness Intact skin Skin discoloration Possible warmth, edema, hardness, pain Stage 2 Pressure Ulcer - correct answer Partial thickness skin loss Shallow open blister with red pink wound bed No slough Stage 3 Pressure Ulcer - correct answer Full thickness skin loss Visible subcutaneous fat and presence of slough May have undermining/tunneling Stage 4 Pressure Ulcer - correct answer Exposed muscle, fat, tendon, bone Slough and eschar May have tunneling/undermining Unstageable Pressure Ulcer - correct answer Depth unknown Obscured by slough or eschar Suspected Deep Tissue Injury - correct answer Depth unknown Localized area of discolored intact skin or blood-filled blister Granulation tissue appearance - correct answer Red, moist, composed of new blood vessels Slough appearance - correct answer Stringy substance in wound bed; yellow or white Eschar appearance - correct answer Black/brown necrotic tissue Acute wound - correct answer Orderly and timely reparative process that results in restoration of skin integrity Wound edges clean and intact Usually caused by trauma, surgical incision Chronic wound - correct answer Fails to proceed through orderly and timely process Usually caused by vascular compromise, chronic inflammation, or repetitive insults to tissue Healing by primary intention - correct answer Edges are approximated Low infection risk FAster healing and minimal scar tissue Healing by secondary intension - correct answer Loss of tissue Wound is left open and filled with scar tissue Longer healing time Risk for infection Partial thickness wound repair - correct answer Inflammatory response -> epithelial proliferation/migration -> re-establishment of epidermal layers Full thickeness wound repair - correct answer 1) hemostasis 2) inflammatory phase 3) proliferative phase 4) maturation Complications of wound healing - correct answer Hemorrhage Infection Dehiscence Evisceration What is a hematoma and why can it be dangerous? - correct answer Localized collection of blood under tissues Sign of internal hemorrhage Could obstruct blood flow if near an artery or vein What is dehiscence and who is at risk? - correct answer Incision fails to heal properly and skin/tissue layers separate @ risk: obese, patient with poor wound healing, abdominal surgery pts, coughing, vomiting, sitting up What is evisceration? - correct answer Protrusion of visceral organs through wound opening What should you do if a patient's wound has eviscerated? - correct answer 1) Place sterile gauze soaked in sterile saline over extruding tissue to decrease risk of bacteria entering and tissue drying 2) Contact surgical team 3) Observe patient for shock 4) Keep pt NPO and prepare for surgery What does serous drainage look like? - correct answer Clear, watery plasms What does purulent drainage look like? - correct answer Thick, yellow, green, tan or brown What does serosanguineous drainage look like? - correct answer Pale, pink, watery What does sangeuineous drainage look like? - correct answer Bright red; active bleeding Categories of the Braden Scale - correct answer Sensory perception Moisture Activity Mobility Nutrition Friction and shear Scores of the Braden Scale - correct answer Scale of 6-23 Each category worth 1-4 points General adults: <18 is @ risk Intensive care: <13 is @ risk Factors influencing formation and healing - correct answer Nutrition Tissue perfusion Infection Age Psychosocial impact What are some psychosocial concerns a patient with a wound may have? - correct answer Body image -> stress Self concept