Nurse 3280 || 100% Accurate Answers.
epidermis correct answers outermost layer contains the subcutaneous gland.
dermis correct answers second most outermost layer. Contains hair follicle and papilla.
subcutaneous layer correct answers bottom layer of the skin containing fatty tissue
functions of the skin correct answers Protection
Temp regulation
Psychosocial- body image etc.
Sensation
Vitamin D production
Immunologic
Absorption
Elimination
four main pigments of skin correct answers Melanin
Carotene
Oxygenated hemoglobin
Reduced hemoglobin
factors affecting skin integrity correct answers First line of defense
Adequately nourished or hydrated
Age or chronic illness
Adequate circulation
developmental considerations of the skin correct answers Younger than 2 skin is weaker than
adults.
Infants' skin and mucous membranes are easily injured.
The structure of the skin as a person ages.
Circulation and collagen are impaired.
causes of skin alterations correct answers Obesity
Cachexia
Excessive perspiration
Eczema or psoriasis-
cachexia correct answers less than appropriate amount of body nutrients.
excessive perspiration of the skin correct answers skin constantly being moist. Sweating etc.
eczema or psoriasis correct answers autoimmune condition that can cause itchiness or
pain.overgrowth of the epidermis can cause red or silver plaques.
types of wounds correct answers intentional
open
acute
,intentional wound correct answers a wound that is the result of a planned surgical or medical
intervention
appears to have a previous site. or unintentional- injury
open wound correct answers an injury in which the skin is interrupted, exposing the tissue
beneath.
margians no touching or closed- severe
acute wound correct answers injury fracture etc. or chronic- wound that has been attempting
to heal over a long period of time.
phases of wound healing correct answers Hemostasis
Inflammatory
Proliferation
Maturation
Hemostasis (wound healing) correct answers blood clotting begins, exudate is formed,
swelling and pain can occur.
inflammatory phase (wound healing) correct answers lasts 2-3 days, white blood cells move
to the wound. Mild fever and pain.
Proliferative phase (wound healing) correct answers several weeks, new tissue built into
wound space. Collagen and capillaries are repaired.
maturation phase (wound healing) correct answers can take months to years. Scar may form
from collagen deposition
scar tissue never correct answers works as normal as tissue
factors affecting wound healing correct answers Pressure
Desiccation
Maceration
Trauma
Edema
Infection
Excessive bleeding
Necrosis
Biofilm
recognizing differences in skin colors is correct answers important
recognize how symptoms show up on different skin colors
factos affecting wound healing (systemic) correct answers Age
Circulation and oxygenation
Nutritional status
Wound etiology
Medications and health status
immunosuppression
Adherence to treatment plan.
,wound complications correct answers infection
drainage
hemorrhage
dehiscence and evisceration
fistula formation
infection correct answers wound drainage
hemorrhage correct answers bright red bleeding on wound site
Dehiscence and evisceration correct answers surgical wound becomes open
pressure injury correct answers Localized damage to the skin and underlying tissue that
usually occurs over a bony prominence.
factors affecting pressure injury development correct answers External pressure: bony
prominences
Friction: two surfaces rub together
Shear- one layer of tissue slides over another.
Aging skin
Chronic illnesses
Immobility
Malnutrition Fecal and urinary continence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders.
at risk for pressure injury correct answers Elderly
ICU patients
Ability or sensory deficit patients.
stage 1 pressure ulcer correct answers Nonblanchable erythema of intact skin
Changes in temp, sensation, and firmness.
Color changes are not purple or maroon.
stage 2 pressure ulcer correct answers Partial - thickness loss of skin with exposed dermis.
Wound bed is pink, red, and moist.
Adipose tissues are not visible.
Granulation tissue, slough, and eschar are not present.
stage 3 pressure ulcer correct answers full - thickness loss of skin.
Adipose tissue is visible in ulcer and granulation tissue are present.
Slough and or eschar may be visible
Undermining and tunneling may occur
Fascia, muscle, tendon, ligament, cartilage, and / or bone are not exposed.
stage 4 pressure ulcer correct answers Full thickness skin and tissue loss which the extent of
tissue damage with ulcer cannot be confirmed due to being obscured by slough or eschar.
, unstageable Presser ulcer correct answers Full thickness skin and tissue loss which the extent
of tissue damage with ulcer cannot be confirmed due to being obscured by slough or eschar.
Braden skin score correct answers Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear.
measurement of pressure injury correct answers Size
Depth
Presence of undermining tunneling or sinus tracts.
cleaning pressure injury / wound correct answers Clean with each dressing change.
Use new gauze for each wipe and clean from top to bottom and or from center to outside.
Use .9% normal saline solution to irrigate and clean the injury.
Once the wound is cleaned, dry the area using a gauze sponge in the same manner.
Report any drainage or necrotic tissue.
Assessment of Wound Drainage correct answers serous, sanguineous, serosanguineous,
purulent
serous correct answers transparent- or yellow or clear.
purulent correct answers presence of White Blood Cell- Pus.
Serosanguinous correct answers presence of fluids. Usually red.
Sanguineous correct answers blood clot.
wound assessment correct answers inspection
palpation.
sutures
wound inspection correct answers sight and smell
wound palpation correct answers appearance, pain, drianage
wound sutures correct answers tubes, drains, complications
purpose of wound dressing correct answers Provide physical. Psychological and aesthetic
comfort.
Prevent, eliminate, or control infection
Absorb drainage
Maintain moisture
Protect wounds from further injury.
Protect the skin surrounding the wound
Debride (remove damaged / necrotic tissue) if appropriate
Stimulate and or optimize the healing response
epidermis correct answers outermost layer contains the subcutaneous gland.
dermis correct answers second most outermost layer. Contains hair follicle and papilla.
subcutaneous layer correct answers bottom layer of the skin containing fatty tissue
functions of the skin correct answers Protection
Temp regulation
Psychosocial- body image etc.
Sensation
Vitamin D production
Immunologic
Absorption
Elimination
four main pigments of skin correct answers Melanin
Carotene
Oxygenated hemoglobin
Reduced hemoglobin
factors affecting skin integrity correct answers First line of defense
Adequately nourished or hydrated
Age or chronic illness
Adequate circulation
developmental considerations of the skin correct answers Younger than 2 skin is weaker than
adults.
Infants' skin and mucous membranes are easily injured.
The structure of the skin as a person ages.
Circulation and collagen are impaired.
causes of skin alterations correct answers Obesity
Cachexia
Excessive perspiration
Eczema or psoriasis-
cachexia correct answers less than appropriate amount of body nutrients.
excessive perspiration of the skin correct answers skin constantly being moist. Sweating etc.
eczema or psoriasis correct answers autoimmune condition that can cause itchiness or
pain.overgrowth of the epidermis can cause red or silver plaques.
types of wounds correct answers intentional
open
acute
,intentional wound correct answers a wound that is the result of a planned surgical or medical
intervention
appears to have a previous site. or unintentional- injury
open wound correct answers an injury in which the skin is interrupted, exposing the tissue
beneath.
margians no touching or closed- severe
acute wound correct answers injury fracture etc. or chronic- wound that has been attempting
to heal over a long period of time.
phases of wound healing correct answers Hemostasis
Inflammatory
Proliferation
Maturation
Hemostasis (wound healing) correct answers blood clotting begins, exudate is formed,
swelling and pain can occur.
inflammatory phase (wound healing) correct answers lasts 2-3 days, white blood cells move
to the wound. Mild fever and pain.
Proliferative phase (wound healing) correct answers several weeks, new tissue built into
wound space. Collagen and capillaries are repaired.
maturation phase (wound healing) correct answers can take months to years. Scar may form
from collagen deposition
scar tissue never correct answers works as normal as tissue
factors affecting wound healing correct answers Pressure
Desiccation
Maceration
Trauma
Edema
Infection
Excessive bleeding
Necrosis
Biofilm
recognizing differences in skin colors is correct answers important
recognize how symptoms show up on different skin colors
factos affecting wound healing (systemic) correct answers Age
Circulation and oxygenation
Nutritional status
Wound etiology
Medications and health status
immunosuppression
Adherence to treatment plan.
,wound complications correct answers infection
drainage
hemorrhage
dehiscence and evisceration
fistula formation
infection correct answers wound drainage
hemorrhage correct answers bright red bleeding on wound site
Dehiscence and evisceration correct answers surgical wound becomes open
pressure injury correct answers Localized damage to the skin and underlying tissue that
usually occurs over a bony prominence.
factors affecting pressure injury development correct answers External pressure: bony
prominences
Friction: two surfaces rub together
Shear- one layer of tissue slides over another.
Aging skin
Chronic illnesses
Immobility
Malnutrition Fecal and urinary continence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders.
at risk for pressure injury correct answers Elderly
ICU patients
Ability or sensory deficit patients.
stage 1 pressure ulcer correct answers Nonblanchable erythema of intact skin
Changes in temp, sensation, and firmness.
Color changes are not purple or maroon.
stage 2 pressure ulcer correct answers Partial - thickness loss of skin with exposed dermis.
Wound bed is pink, red, and moist.
Adipose tissues are not visible.
Granulation tissue, slough, and eschar are not present.
stage 3 pressure ulcer correct answers full - thickness loss of skin.
Adipose tissue is visible in ulcer and granulation tissue are present.
Slough and or eschar may be visible
Undermining and tunneling may occur
Fascia, muscle, tendon, ligament, cartilage, and / or bone are not exposed.
stage 4 pressure ulcer correct answers Full thickness skin and tissue loss which the extent of
tissue damage with ulcer cannot be confirmed due to being obscured by slough or eschar.
, unstageable Presser ulcer correct answers Full thickness skin and tissue loss which the extent
of tissue damage with ulcer cannot be confirmed due to being obscured by slough or eschar.
Braden skin score correct answers Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear.
measurement of pressure injury correct answers Size
Depth
Presence of undermining tunneling or sinus tracts.
cleaning pressure injury / wound correct answers Clean with each dressing change.
Use new gauze for each wipe and clean from top to bottom and or from center to outside.
Use .9% normal saline solution to irrigate and clean the injury.
Once the wound is cleaned, dry the area using a gauze sponge in the same manner.
Report any drainage or necrotic tissue.
Assessment of Wound Drainage correct answers serous, sanguineous, serosanguineous,
purulent
serous correct answers transparent- or yellow or clear.
purulent correct answers presence of White Blood Cell- Pus.
Serosanguinous correct answers presence of fluids. Usually red.
Sanguineous correct answers blood clot.
wound assessment correct answers inspection
palpation.
sutures
wound inspection correct answers sight and smell
wound palpation correct answers appearance, pain, drianage
wound sutures correct answers tubes, drains, complications
purpose of wound dressing correct answers Provide physical. Psychological and aesthetic
comfort.
Prevent, eliminate, or control infection
Absorb drainage
Maintain moisture
Protect wounds from further injury.
Protect the skin surrounding the wound
Debride (remove damaged / necrotic tissue) if appropriate
Stimulate and or optimize the healing response
