Skin Integrity and Wound Care
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| ________________ is the term used to describe impaired skin integrity resulting form pressure. | show 🗑
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| A patient experiencing decreased mobility, inadequate nutrition, decreased sensory perception, or decreased activity is a risk for ________________ development. | show 🗑
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| show | tissue ischemia
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| ________________ is an area of skin that appears red and warm and will turn lighter in color following fingertip palpation. | show 🗑
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| ________________ is redness that persists after palpation and indicates tissue damage. | show 🗑
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| show | shear
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| ________________ is an injury to the skin that has the appearance of an abrasion. | show 🗑
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| ________________ on the skin increases the risk of ulcer formation. | show 🗑
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| Poor nutrition, specifically severe ________________, causes soft tissue to become susceptible to breakdown. | show 🗑
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| show | protein levels
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| show | severe protein loss
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| serum albumin level below 3 g/100 mL | show 🗑
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| show | total protein
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| show | edema
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| ________________ is generalized ill health and malnutrition, marked by weakness and emaciation. | show 🗑
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| show | emaciation
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| show | infection
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| Infection and fever increase the ________________ of the body, making already hypoxic tissue more susceptible to ischemic injury. | show 🗑
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| show | age
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| ________________ are at highest risk for development of pressure ulcers. | show 🗑
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| 60% to 90% of all pressure ulcers occur in patients over ________________ years of age. | show 🗑
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| show | pressure ulcers
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| show | 12 to 32 mm Hg
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| The ulcer appears a s defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones the ulcer appears with persistent red, blue, or purple hues and the skin intact. | show 🗑
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| Partial-thickness skin loss involving epidermis, dermis, or both; the ulcer is superficial and presents as an abrasion, blister, or shallow crater (skin is broken). | show 🗑
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| show | stage III
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| show | stage IV
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| dead, dry tissue | show 🗑
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| A wound with little or no tissue loss, such as a clean surgical incision, heals by ________________. | show 🗑
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| when skin edges are close together | show 🗑
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| show | secondary intention
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| The wound heals with a layer of ________________ at the edges and base, and several day s after the initial wounding the wound edges are brought together with sutures or adhesive closures. | show 🗑
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| ________________ are the first response to a partial-thickness wound repair, bringing white blood cells to the site. | show 🗑
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| show | red and swollen
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| During the inflammatory response of a partial-thickness wound repair, the ________________, or discharge, if allowed to dry, brings the white blood cells to the area and a scab will form. | show 🗑
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| show | 24 hours
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| Peak epithelial proliferation occurs within ________________ after injury. | show 🗑
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| peak epithelial proliferation | show 🗑
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| Wounds kept in a moist environment will heal in approximately ________________ (as opposed to 7 days when kept dry) b/c new epithelial cells migrate across a moist surface. | show 🗑
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| With ________________ , the epidermis thickens, anchors to adjacent cells, and resumes normal function and looks pink, dry, and fragile. | show 🗑
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| During full-thickness wound repair, the first event of ________________ is hemostasis. | show 🗑
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| show | platelets
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| The ________________ during full-thickness wound repair lasts approximately 3 days in an acute clean wound, such as a surgical incision. | show 🗑
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| The key events in the ________________ of full-thickness wound repair are production of new tissue, epithelialization, and contraction. | show 🗑
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| show | remodeling phase
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| The tensile strength of the scar tissue during the remodeling phase of full-thickness wound repair is never more than ________________ of the tensile strength in non-wounded tissue. | show 🗑
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| show | hemostasis
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| hemostasis | show 🗑
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| collection of clotted blood | show 🗑
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| show | bacterial wound infection
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| A contaminated or traumatic wound infection develops within ________________. | show 🗑
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| A surgical wound infection develops within ________________. | show 🗑
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| show | systemic signs
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| ________________ is the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly. | show 🗑
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| show | obese patients
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| Dehiscence occurs most often in ________________ after a sudden strain such as coughing, vomiting, or sitting up in bed. | show 🗑
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| show | serosanguineous
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| ________________ occurs when wound layers separate below the fascial layer, and visceral organs protrude through the wound opening. | show 🗑
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| A ________________ is an abnormal opening between two organs or between an organ and the skin. | show 🗑
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| show | fistulas
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| In the ________________, some patients require well-though-out modifications of wound care techniques. | show 🗑
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| show | darker
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| show | natural or halogen
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| show | tissue consistency
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| Skin assessment for the patient with intact darkly pigmented skin: assess for for firm or ________________ feel. | show 🗑
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| Skin assessment for the patient with intact darkly pigmented skin: skin may feel initially ________________, but subsequently may feel ________________. | show 🗑
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| show | incontinence skin barriers
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| show | lift sheets
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| Maintain head of bed at , or below ________________ or at the lowest level of elevation consistent with the patient's medical condition. | show 🗑
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| Avoid ________________ over bony prominences. | show 🗑
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| show | hyperemia
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| Turning time - arrhythmia time = | show 🗑
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| If you suspect ________________, outlining the affected area with a marker makes reassessment easier. | show 🗑
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| show | impaired skin integrity
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| show | malnutrition
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| Inadequate caloric intake causes ________________ and a decrease in subcutaneous tissue, allowing bony prominences to compress and restrict circulation. | show 🗑
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| The ________________ is less tolerant to pressure, friction, and shear b/c of decreased elasticity from normal aging. | show 🗑
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| show | 59% to 85%
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| The thinning of the dermis and flattening of the dermal-epidermal junction that occur in aging predispose the older adult's skin to ________________. | show 🗑
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| show | loss of dermis
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| An ________________ is usually superficial with little bleeding but some weeping. | show 🗑
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| show | abrasion
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| A ________________ is damage to the dermis and epidermis and is a torn, jagged wound. | show 🗑
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| The depth and location of the ________________ affect the extent of bleeding, with serous bleeding possible in lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep. | show 🗑
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| ________________ bleed in relation to the depth and size of the wound. | show 🗑
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| Internal bleeding and infection are the ________________ of puncture wounds. | show 🗑
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| 3 steps of assessing a puncture wound: 1. inspect the wound for ________________. | show 🗑
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| 3 steps of assessing a puncture wound: 2. assess the ________________ of the wound and the need for suturing or surface protection. | show 🗑
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| show | tetanus toxoid
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| show | saturated dressing
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| When you plan a dressing change, give the patient an analgesic at least ________________ before exposing a wound. | show 🗑
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| Risk for malnutrition: age: < ________________ years or > ________________ years. | show 🗑
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| show | 5 to 10%
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| show | 3.0
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| show | 5.0
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| show | superficial bleeding under the skin or a mucous membrane; a bruise
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| show | wound drainage
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| show | clear, watery plasma
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| Types of wound drainage: sanguineous | show 🗑
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| show | pale, more watery, a combination of plasma and red cells, may be blood-streaked
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| Types of wound drainage: purulent | show 🗑
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| Note the character and amount of drainage if there is a ________________. | show 🗑
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| show | physician or health care provider
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| show | cellulitis
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| show | light palpation
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| Pain assessment is an important component of ________________ for detecting complications and planning for future wound care. | show 🗑
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| Never collect a wound culture sample from ________________, b/c resident colonies of bacteria grow in exudate. | show 🗑
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| show | aerobic specimen
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| Nursing diagnoses relevant to wound care: risk for ________________ | show 🗑
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| show | physical mobility
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| show | impaired
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| Nursing diagnoses relevant to wound care: imbalanced nutrition: ________________ | show 🗑
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| show | acute
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| Nursing diagnoses relevant to wound care: ________________ pain | show 🗑
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| show | self-esteem
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| show | skin integrity
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| show | skin integrity
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| Nursing diagnoses relevant to wound care: ineffective ________________ | show 🗑
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| ________________ for predicting pressure sore risk | show 🗑
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| show | 16
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| show | <=9
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| show | massage
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| When cleansing the skin, use a ________________ agent. | show 🗑
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| show | moisture barrier
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| Most underpads and briefs have a ________________ that holds moisture against skin. | show 🗑
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| Diapers and underpads will ________________ the skin if left under patients for prolonged periods of time. | show 🗑
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| show | 1 to 2 hours
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| The WOCN recommends reducing ________________ by keeping the patient's head of bed below the 30-degree angle, using assistive devices when turning or transferring patients, using the bed gatch or footboard, and using the 30-degree lateral position. | show 🗑
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| show | hour
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| show | 15 minutes
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| ________________ decrease teh amount of pressure exerted over bony prominences by maximizing contact (allowing the body to touch the entire surface) and thereby redistributing weight over a large area. | show 🗑
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| show | support surface
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| show | at-risk individuals
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| Avoid using foam rings, donuts, and sheepskin for ________________. | show 🗑
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| show | foam rings and donuts
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| The patient must receive ________________ to achieve wound healing. | show 🗑
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| ________________ is necessary to support new blood vessels and collagen synthesis. | show 🗑
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| show | wound healing
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| B/c ________________ causes problems with wound healing, blood glucose control is essential. | show 🗑
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| show | stable wound
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| To maintain a ________________ it is important to control infection and promote cleansing, debridement, exudate management, control of dead space, and wound protection. | show 🗑
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| Assess the patient with a ________________ for signs and symptoms of a wound infection: redness, warmth of surrounding tissue, odor, and the presence of exudate. | show 🗑
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| show | dressing change
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| show | necrotic tissue
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| Cleanse dirty wounds with ________________. | show 🗑
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| Clean wounds require only gentle flushing with ________________. | show 🗑
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| show | moist wound environment
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| show | wound moisture
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| show | puncture wound
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| If a ________________ is in a patient's body, do not remove the object. | show 🗑
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| show | cleansing
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| ________________ causes bleeding or further injury. | show 🗑
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| Ideally a ________________ provides a moist environment to promote normal epidermal cell migration. | show 🗑
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| The proper dressing will absorb ________________ to prevent polling of exudate that promotes bacterial growth. | show 🗑
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| show | wound drainage
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| A dressing ________________ wound exposure to microorganisms. | show 🗑
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| show | fibrin seal
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| show | hemostasis
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| show | normal healing
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| Assess skin color, pulses in distal extremities, patient comfort, and any changes in sensation to ensure pressure dressings do not interfere with ________________. | show 🗑
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| show | dry dressing
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| The purpose of a ________________ dressing is to act as a sponge, absorbing excessive wound drainage, while providing a moist environment. | show 🗑
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| ________________ is the most common dressing type. | show 🗑
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| ________________ does not interact with wound tissues and thus causes little wound irritation. | show 🗑
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| ________________ are useful in debriding wounds. | show 🗑
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| The process of softening a solid by steeping in a fluid. | show 🗑
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| ________________ dressings are clear sheets coated on one side with an adhesive. | show 🗑
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| Transparent film dressings are used as a ________________ in wounds with minimal tissue loss that have very little wound draingage. | show 🗑
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| You change a transparent film dressing when the seal is ________________. | show 🗑
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| show | hydrocolloid
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| ________________ form a gel as they interact with the wound surface. | show 🗑
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| ________________ dressings are available in sheets or in a gel in a tube (amorphous). | show 🗑
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| show | 1 to 3 days
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| A new treatment for chronic wounds is the wound ________________. | show 🗑
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| Wound closure applies ________________ to the wound to promote and accelerate healing. | show 🗑
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| show | reinforce dressing prn
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| show | surgery
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| Use tape, ties, or bandages and cloth binders to secure a ________________ over a wound site. | show 🗑
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| show | Montgomery ties
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| show | least; most
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| Do not use povidone-iodine (Betadine0, hydrogen peroxide, and acetic acid (vinegar) to irrigate a ________________. They kill ________________, a key component in wound healing. | show 🗑
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| When ________________, allow the solution to flow from the least contaminated to the most contaminated area. | show 🗑
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| Administer the prescribed solution at ________________ to enhance comfort and provide local cleansing application. | show 🗑
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| When irrigating clean wounds, use sterile technique and an irrigation system with a safe pressure (________________) to prevent trauma to the newly formed granulation tissue. | show 🗑
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| show | psi of 8
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| ________________ are threads or wires made of silk, steel, cotton, nylon, and polyester (Dacron) and are used to sew body tissues together. | show 🗑
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| ________________ are convenient, portable units that connect to tubular drains within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. | show 🗑
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| Before applying a bandage or binder, perform the following steps: 1. Inspect the ________________ for abrasions, edema, discoloration, or exposed wound edges. | show 🗑
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| show | sterile dressing
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| Before applying a bandage or binder, perform the following steps: 3. Assess the condition of ________________, and change if they are soiled. | show 🗑
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| Before applying a bandage or binder, perform following steps: 4. Assess skin of ________________ & parts that will be distal to bandage for signs of circulatory impairment to provide a means for comparing changes in circulation after bandage application. | show 🗑
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| show | breast binder
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| show | heat and cold
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| Systemic responses occur through ________________ (sweating or vasodilation) or mechanisms promoting heat conservation (vasocontriction or piloerection) and heat production (shivering). | show 🗑
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| show | heat
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| show | heat
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| show | heat
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| show | cold
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| Factors influencing heat & cold tolerance: 1. duration of application - a person is better able to tolerate ________________ to any temperature extremes. | show 🗑
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| show | more; less
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| show | more
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| Factors influencing heat & cold tolerance: 4. Prior skin temperature - The ________________ responds best to minor temperature adjustments. | show 🗑
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| Factors influencing heat & cold tolerance: 5. Body surface area - A person is ________________ of temperature changes over a large area of the body. | show 🗑
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| show | most
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| If the patient has ________________, it is unwise to apply heat to large portions of the body b/c massive vasodilation will disrupt blood supply to vital organs. | show 🗑
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| Cold is ________________ if the site of injury is edematous or the patient has impaired circulation or is shivering (may intensify shivering and reduce blood flow). | show 🗑
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| The patient who has had rectal surgery or an episiotomy during childbirth or who has painful hemorrhoids or vaginal inflammation will benefit from a ________________, a bath in which only the pelvic area is immersed in warm fluid. | show 🗑
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| show | improves blood flow to injury body part; example: arthritis or degenerative joint disease
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| heat therapy: reduced blood viscosity | show 🗑
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| heat therapy: reduced muscle tension | show 🗑
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| show | provides local warmth; example: hemorrhoidal, perianal, and vaginal inflammation
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| show | promotes movement of waste products and nutrients; example: local abscesses
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| show | reduces blood flow to injured site, preventing edema formation; example: immediately after direct trauma (e.g., sprains, strains, fractures, muscle spasms)
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| show | reduces localized pain; example: superficial laceration or puncture wound
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| cold therapy: reduced cell metabolism | show 🗑
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| show | promotes blood coagulation at injury site; example: after injections
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| cold therapy: decreased muscle tension | show 🗑
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| show | thinner skin layers increase risk of burns; ________________ have reduced sensitivity to pain
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| show | subcutaneous tissue is more sensitive to temperature variations
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| Conditions that increase risk of injury from heat and cold application: areas of edema or scar formation | show 🗑
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| show | body's extremities are less sensitive to temp. & pain stimuli b/c of circulatory impairment & local tissue injury; cold application further compromises blood flow
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| Conditions that increase risk of injury from heat and cold application: confusion or unconsciousness | show 🗑
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| Conditions that increase risk of injury from heat and cold application: spinal cord injury | show 🗑
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| show | same results - potential pressure ulcers
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| show | sensory deficit
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| show | sensory deprivation
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| When a person receives multiple sensory stimuli, the brain has difficulty distinguishing the stimuli that causes a ________________ to occur. | show 🗑
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| a common progressive hearing disorder in older adults | show 🗑
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| show | presbyopia
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| show | antibiotics, diuretics, analgesics/NSAIDs, antineoplastic agents
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| gustatory | show 🗑
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| show | position and movement in space
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| show | smell
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
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You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
chaptravelman
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