Skin Integrity- Test 3

Front 1

An _____ is a type of wound that is usually intentional, open, and can be shallow or deep.

Back 1

incision

Front 2

A _____ is a closed wound with bruising and soft tissue damage. It is usually unintentional and can be caused by a blow or fall.

Back 2

contusion

Front 3

An _____ is an open wounds that could be intentional or unintentional. An example would be a scraped knee.

Back 3

abrasion

Front 4

A _____ is an open wound that may be intentional or unintentional. It is a penetration of the skin sometimes into underlying layers.

Back 4

puncture

Front 5

An example of a puncture wound is a ______.

Back 5

knife wound

Front 6

A _____ is an open wound that is usually unintentional. The tissue is torn apart and sometimes edges are jagged.

Back 6

laceration

Front 7

A _____ wound is unintentional and has more velocity to it.

Back 7

penetrating

Front 8

An example of a penetrating wound is a ______.

Back 8

gun shot wound

Front 9

_______ is a term used to describe surgical wounds; edges are clean and close together with no gaps.

Back 9

Well approximated

Front 10

3 processes of wound healing are:

Back 10

-primary intention
-secondary intention
-tertiary intention

Front 11

_____ intention is a wound that has little or no tissue loss. It is a nice clean surgical incision.

Back 11

Primary

Front 12

______ intention is a wound involving loss of tissue. There is a longer healing time, bigger scar and greater chance of infection.

Back 12

Secondary

Front 13

_____ intention is when healing occurs when the interval between the wound's occurrence and its suturing is extended. There are very large scars and a huge chance of infection.

Back 13

Tertiary

Front 14

Wounds can be classified as ______ or ____ thickness.

Back 14

partial or full

Front 15

A _____ thickness wound is confined to dermis and epidermis. It heals by regeneration (primary or secondary intention).

Back 15

Partial

Front 16

A _____ thickness wound involves the dermis, epidermis, SQ tissue and possibly supporting structures (muscles). It must have tissue repair to heal.

Back 16

full

Front 17

The 3 phases of wound healing are:

Back 17

-inflammation
-proliferation
-maturation

Front 18

_____ is the phase of wound healing that occurs right after surgery. It is when phagocytosis occurs. The patient may be lethargic and have a low fever.

Back 18

Inflammation

Front 19

_____ is the phase of wound healing that happens between 4 days and 3 weeks. Granulation tissue is present.

Back 19

Proliferation

Front 20

_____ is the phase of wound healing that begins after the third week. This is when the scar is formed.

Back 20

Maturation

Front 21

Scars are not as strong as normal tissue and don't ____, grow ____, or _____.

Back 21

sweat
hair
tan

Front 22

An overgrowth of scar tissue is a ______.

Back 22

keloid

Front 23

______ bleeds easily but is good and means the wound is healing. DON'T SCRUB!

Back 23

Granulation tissue

Front 24

Factors affecting wound healing are:

Back 24

-patient age
-circulation and oxygenation
-nutrition
-wound condition
-overall patient health

Front 25

Medications such as Ibuprofen and NSAIDS _____ wound healing.

Back 25

slow

Front 26

Wound healing complications are:

Back 26

infection
hemorrhage
hematoma
dehiscence
evisceration
fistula

Front 27

A _____ is internal bleeding.

Back 27

hemorrhage

Front 28

A ______ sometimes forms at the site of a wound.

Back 28

hematoma

Front 29

_____ is the opening of the wound.

Back 29

Dehiscence

Front 30

When the incision opens and visceral organs protrude it is called _______.

Back 30

evisceration

Front 31

If evisceration occurs the nurse should..

Back 31

cover organs with moist sterile saline towels.

Front 32

A _____ occurs when an infection causes a tubelike passage from an organ to the surface of the skin or to another organ.

Back 32

fistula

Front 33

The psychosocial effects of wounds are:

Back 33

-pain
-anxiety and fear
-alteration in body image

Front 34

When assessing the wound, the nurse should note...

Back 34

-inspection of skin and wound
-wound drainage and moisture status
-wound age
-wound size
-wound color
-stage of pressure ulcer
-presence of infection
-palpation (texture and temperature)
-sutures and staples
-drains
-ohter

Front 35

4 different types of wound drainage are:

Back 35

-serous
-sanguinous
-serosanguinous
-purulent

Front 36

Drainage that is clear or light yellow and thin and watery is called _____.

Back 36

serous

Front 37

_____ drainage is seen after the wound has started healing. It is the last stages of sound healing.

Back 37

Serous

Front 38

Drainage that is red with fresh blood and thin is called ______.

Back 38

sanguinous

Front 39

_____ drainage is likely to be seen on the first dressing when the patient returns from surgery.

Back 39

Sanguinous

Front 40

Wound inspection occurs when the nurse looks at the wound to determine whether it is

Back 40

healing well.

Front 41

Drainage that is pink to light red and thin or watery is called ______.

Back 41

serosanguinous

Front 42

Drainage that is yellow, green, white, or tan, and thick and opaque is called _____.

Back 42

purulent

Front 43

______ drainage is not good and means there is infection.

Back 43

Purulent

Front 44

Wound age can be described as ____ or _____.

Back 44

acute or chronic

Front 45

New wounds that are making progress towards healing are called ______.

Back 45

acute

Front 46

Old wounds that have slowed or stopped healing and are stuck in the inflammatory phase are called ______.

Back 46

chronic

Front 47

Wound size can be measured _____, _____, and _____.

Back 47

hip to hip
head to toe
depth

Front 48

When measuring wound size the nurse should...

Back 48

-measure wound
-note presence of tunneling
-note presence of undermining

Front 49

_____ starts in the SQ tissue and goes thru. It occurs with high bacterial load in the wound and the location is described using clock directions.

Back 49

Tunneling

Front 50

______ is a pocket between the skin and SQ tissue.

Back 50

Undermining

Front 51

Color of wounds is described using the ____ color code.

Back 51

RYB

Front 52

A wound with ____ is in the late regeneration stage. This type of skin is good and should be protected therefore clean very gently.

Back 52

red

Front 53

If there is ____ inside a wound it must come out thru debridement or absorbent dressings. It is slough and granulation tissue will not grow in the presence of slough.

Back 53

yellow

Front 54

____ tissue in a wound indicates necrosis or eschar. Debridement is necessary and will be done surgically by a physician.

Back 54

Black

Front 55

Wound care cleaning procedures include:

Back 55

-hand hygiene
-acute wounds: clean head to toe/top to bottom with saline or sterile water.
-chronic wounds: probably big; clean inside out in a circular motion with saline and irrigation

Front 56

Cleaning a _____ wound requires saline or sterile water and a head to toe/top to bottom method.

Back 56

acute

Front 57

Don't use ____ to clean a wound because it impedes wound healing.

Back 57

hydrogen peroxide

Front 58

Cleaning a ____ sound requires saline and irrigation; clean inside out and in a circular motion.

Back 58

chronic

Front 59

A localized injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from pressure in combination with shear, and/or friction is a _____.

Back 59

pressure ulcer

Front 60

Other names for pressure ulcers are

Back 60

bed sore
decubitis ulcer

Front 61

Pressure ulcers usually develop over _____.

Back 61

bony areas

Front 62

____ and ____ are major factors in pressure ulcers.

Back 62

Friction and shear

Front 63

A perpendicular force or load exerted on a specified area causing ischemia and hypoxia is _____.

Back 63

pressure

Front 64

______ is a mechanical force occurring when two surfaces move across one another.

Back 64

Friction

Front 65

Friction injuries appear as an ____ or _____.

Back 65

abrasion or superficial laceration

Front 66

A patient sliding down in the bed is an example of _____.

Back 66

friction

Front 67

_____ is a mechanical force that acts on a area of skin in a direction parallel to the body surface.

Back 67

Shear

Front 68

Friction works with gravity to cause _____.

Back 68

shear

Front 69

If patient is at risk for friction or shearing, do not elevate the HOB to more than ______ unless eating.

Back 69

30 degrees

Front 70

When assessing the client risk factors affecting pressure ulcer development, the nurse should examine:

Back 70

-immobility and mobility
-nutrition and hydration
-moisture on skin
-mental status
-diminished sensation
-friction and shear
-age

Front 71

Alert patients are at ____ risk for pressure ulcers.

Back 71

decreased

Front 72

Low mobility ____ patient risk for developing a pressure ulcer.

Back 72

increases

Front 73

Poor nutrition causes cells to be _______.

Back 73

damaged easily

Front 74

Diminished sensation _____ risk of developing a pressure ulcer.

Back 74

increases

Front 75

The most common pressure point is the ______.

Back 75

sacrum

Front 76

Areas that are assessed on the Braden Scale are:

Back 76

-sensory perception
-moisture
-activity
-mobility
-nutrition
-friction and shear

Front 77

In order to prevent pressure ulcers, nurses should take the following precautions:

Back 77

-identify at risk clients using Braden scale
-assess skin areas
-turn the client
-position bed (<30 degrees)
-good hygiene and nutrition
-protect client's skin
-early intervention
-barrier creams
-pressure reducing beds
-booties
-don't massage over bony prominences
-use lift sheet or trapeze bar
-manage incontinence

Front 78

A ____ pressure ulcer has skin that is intact and nonblanching erythema.

Back 78

Stage I

Front 79

A Stage I pressure ulcer requires frequent ______ or _____ or patient q2h or more often.

Back 79

turning or positioning

Front 80

A Stage I pressure ulcer may look _____ in African American or Indian patients.

Back 80

dark blue or purple

Front 81

A ______ pressure ulcer has partial-thickness skin loss. It could look like an abrasion, blister or shallow crater.

Back 81

Stage II

Front 82

Stage II pressure ulcers are treated with _____ and _____.

Back 82

saline and occlusive dressings

Front 83

Stage II pressure ulcers progress no further than _____.

Back 83

dermis

Front 84

A _____ pressure ulcer is full-thickness with damage or necrosis to subcutaneous tissue.

Back 84

Stage III

Front 85

A Stage III pressure ulcer is treated with ____ and possibly _____ to remove necrosis.

Back 85

wet-to-dry dressing
surgery

Front 86

A ______ pressure ulcer is full-thickness with skin loss and damage to the supporting structures.

Back 86

Stage IV

Front 87

A Stage IV pressure ulcer requires _____ dressings, _____ dressings, or even skin grafting.

Back 87

non-adherent
extensive

Front 88

You may see bone in a _____ pressure ulcer.

Back 88

Stage IV

Front 89

A wound vac is sometimes used with _____ pressure ulcers.

Back 89

Stage IV

Front 90

Additional types of chronic ulcers are:

Back 90

-venous ulcers
-diabetic ulcers
-arterial ulcers

Front 91

____ ulcers are caused by venous insufficiency.

Back 91

Venous

Front 92

_____ ulcers are the hardest to heal.

Back 92

Diabetic

Front 93

_____ is the loss of sensation in the lower extremities.

Back 93

Neuropathy

Front 94

_____ is poor perfusion to the lower extremities.

Back 94

PVD- peripheral vascular disease

Front 95

_____ ulcers are caused by arterial insufficiency and seen a lot in people who need femoral popliteal bypass.

Back 95

Arterial

Front 96

When assessing an ulcer, the nurse should note...

Back 96

-location and stage of ulcer
-dimensions of ulcer (measure)
-margins (edges)
-abnormal pathways
-wound appearance
-drainage? granulation tissue?
-stage of wound healing
-pain
-smell

Front 97

Stage of wound healing refers to the presence of ____ or _____.

Back 97

granulation tissue or epitheliazation

Front 98

Granulation tissue is _____.

Back 98

red

Front 99

Epithelialization is when the tissue has ______ because granulation is being covered with epithelial cells.

Back 99

pinked up

Front 100

Treatment of chronic wounds includes:

Back 100

-PREVENTION
-Turn client q2h
-inspect skin q8h
-antibiotic therapy
-compression devices for venous ulcers
-debridement

Front 101

6 types of debridement are:

Back 101

-surgical/sharp
-mechanical
-mechanical dressing changes
-autolytic
-enzymatic
-biologic

Front 102

_____ debridement uses scissors, scalpels, forceps, and lasers to remove necrotic tissue. It is the quickest way to get necrotic tissue out.

Back 102

Surgical/Sharp

Front 103

______ debridement may use levage (water) therapy, or ultrasound.

Back 103

Mechanical

Front 104

______ debridement use wet-to-dry dressing changes q8h.

Back 104

Mechanical dressing changes

Front 105

Wet-to-dry dressing changes are more effective on _____.It is not very effective on necrotic tissue.

Back 105

slough

Front 106

______ debridement consists of hydrocoloidal dressing that is self-adhesive to close the wound up helping to retain moisture and allowing the body's own enzymes to debride the necrotic tissue. It is a pliable dressing that can be contoured.

Back 106

Autolytic

Front 107

Autolytic dressings should be done about _____.

Back 107

every 3 days

Front 108

_____ debridement is bright green. Be sure to only put on tissue that needs cleaning- NOT granulation tissue!

Back 108

Enzymatic

Front 109

______ debridement is the use of medical grade maggots to consume dead tissue and release a proteolytic enzyme that helps break the dead tissue down.

Back 109

Biologic

Front 110

When removing an autolytic dressing, peel from the _____.

Back 110

bottom up

Front 111

Benefits of biologic debridement are that the maggots...

Back 111

-have selective debridement
-disinfect with the enzyme that they release
-promote granulation tissue

Front 112

When using a treatment on a wound, if there is no improvement in ____ change the method.

Back 112

2 weeks

Front 113

Examples of Nsg diagnoses for chronic wounds are:

Back 113

-impaired skin integrity
-risk for impaired skin integrity
-impaired tissue integrity
-risk for infection

Front 114

Impaired skin integrity would be possible nursing diagnosis for ____ and _____ pressure ulcers.

Back 114

Stage I and Stage II

Front 115

Impaired tissue integrity would be possible nursing diagnosis for ____ and _____ pressure ulcers.

Back 115

Stage III and Stage IV

Front 116

When evaluating a client before discharge it is important for the nurse to determine...

Back 116

Did the client develop any pressure areas during the hospital stay?

Front 117

The body's first line of defense is ______.

Back 117

intact skin

Front 118

Skin breakdown must be _____.

Back 118

prevented

Front 119

Skin must be _____ and _____.

Back 119

hydrated and nourished

Front 120

Principles of skin care are:

Back 120

-intact skin is the body's first line of defense
-skin breakdown must be prevented
-skin must be hydrated and nourished
-adequate circulation is required
-skin hygiene is necessary
-skin sensitivity varies with each client