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Detailed and comprehensive answers to a theory exam on skin integrity and wound care. It covers a wide range of topics, including developmental considerations affecting skin integrity, types of wounds, factors affecting wound healing, pressure injuries, and wound care procedures. The answers are presented in a clear and organized manner, making it a valuable resource for healthcare professionals and students studying this subject. Updated for the 2024/2025 academic year and is rated as the best for success, with 100% correct answers. It covers essential concepts such as the phases of wound healing, local and systemic factors affecting wound healing, risk factors for pressure injuries, and proper wound care techniques. By studying this document, students can gain a thorough understanding of the key principles and best practices in skin integrity and wound care, which are crucial for providing high-quality patient care.
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debridement - CORRECT ANSWERS cleaning away devitalized tissue and foreign matter from a wound fistula - CORRECT ANSWERS an abnormal passage from an internal organ to the skin or from one internal organ to another hematoma - CORRECT ANSWERS localized mass of usually clotted blood ischemia - CORRECT ANSWERS deficiency of blood in a particular area maceration - CORRECT ANSWERS softening through liquid; overhydration dehiscence - CORRECT ANSWERS separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound erythema - CORRECT ANSWERS redness of the skin evisceration - CORRECT ANSWERS protrusion of viscera through an incision exudate - CORRECT ANSWERS fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells eschar - CORRECT ANSWERS thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur Pressure drainage - CORRECT ANSWERS death of cells and tissue Skin (essential for maintaining life) - CORRECT ANSWERS What is the largest organ in the body?
Skin, subcutaneous layer, and appendages of the skin - CORRECT ANSWERS What is the integumentary made up of? epidermis & dermis - CORRECT ANSWERS What are the 2 layers of the skin? ·protection-barrier temperature regulation- compensates for both heat and cold psychosocial- external appearance sensation- touch, pain, pressure, temperature vitamin D production-activated by ultraviolet rays from the sun immunologic-triggered when the skin is broken absorption- medications elimination-sweat (water, electrolytes, and nitrogenous wastes) - CORRECT ANSWERS What are the functions of the skin? Fragile, high risk for injury and infection. - CORRECT ANSWERS Developmental considerations affecting skin integrity: Infants Becomes increasingly resistant to injury and infection. Develop immunology - CORRECT ANSWERS Developmental considerations affecting skin integrity:
Child easily damaged - CORRECT ANSWERS Developmental considerations affecting skin integrity: Older adult •Increased risk for injury. •Less capacity to insulate. •Sensation of pressure and pain is reduced - CORRECT ANSWERS Older Adult: •Subcutaneous and dermal tissues become thin. •Skin is dryer and itching may occur - CORRECT ANSWERS Older Adult: Activity of the sebaceous and sweat glands decreases. Prolonged healing time - CORRECT ANSWERS Older Adult: Cell renewal is decreased. This causes? lose elasticity. - CORRECT ANSWERS Older Adult: Collagen fiber is less organized, so it causes skin to? Age lifestyle variables
changes in health state illness Diagnostic measures therapeutic measures - CORRECT ANSWERS Factors that place a person at risk for skin alteration Skin loses elasticity and becomes prone to breakdown - CORRECT ANSWERS Dehydration and malnutrition: If fluid, protein and vitamin C is deficient... Then what occurs? injury - CORRECT ANSWERS Reduced sensation (paralysis, nerve damage):If patient has an inability to sense temperature extremes, pressure, and friction... •Then what is he/she at an increased risk for? It will become compromised and breakdown. Placing the patient at increased risk for injury. - CORRECT ANSWERS The nurse correctly identifies if this patient does not receive adequate nutrition what will most likely happen to the integumentary system? older adults - CORRECT ANSWERS Who is at high risk for pressure ulcers? high protein diets - CORRECT ANSWERS What type of diet promotes healing? Diabetic Ulcer (chronic condition) - CORRECT ANSWERS •Cuts and sores that do not heal. •Lesions on the lower extremities that ulcerate and become necrotic. •Recurrent bacterial and fungal infections.
-They have comprised skin integrity due to instability with blood glucose levels- vascular problems increases delayed healing - CORRECT ANSWERS What compromises individuals with diabetes? Hyperglycemia because it causes more damage; it slows and delays wound healing - CORRECT ANSWERS Is a patient more opt to get a foot ulcer when they are hyper or hypoglycemia? skin breakdown - CORRECT ANSWERS Patients on bed rest have increased risk for
irritant - CORRECT ANSWERS Casts are an ______ to the skin Medications - CORRECT ANSWERS May cause: Allergic skin reactions Photosensitivity Impaired healing redness, dry skin, burns, rashes - CORRECT ANSWERS How may radiation therapy affect skin? Wound - CORRECT ANSWERS · A break or disruption in the normal integrity of the skin and tissues
Purposefully created for therapeutic purposes, Edges are clean and bleeding is controlled, Wound made under (normally) sterile conditions with sterile supplies. Risk for infection is decreased and healing is facilitated - CORRECT ANSWERS What is the risk of infection and healing time for intentional wounds? results from surgery, IV therapy, or lumbar puncture - CORRECT ANSWERS List examples of intentional wounds intentional - CORRECT ANSWERS tattoos and colostomies are examples of _________ wounds Unintentional wounds - CORRECT ANSWERS Result of an accident occur from unexpected trauma, forcible injury, and burns Occurs in an unsterile environment, contamination in likely, Edges are usually jagged and bleeding is uncontrolled High risk for infection and longer healing time - CORRECT ANSWERS What is the risk of infection for and healing time for unintentional wounds? accidents, forcible injury (stabbing, gunshots), and burns - CORRECT ANSWERS List examples of unintentional wounds Open wound - CORRECT ANSWERS occurs from intentional or unintentional trauma.
Incision and abrasion Skin surface is broken, and creates a portal of entry. Increased risk for bleeding, tissue damage, infection, and delayed healing time - CORRECT ANSWERS What are the infection risks and healing time for open wounds? incisions and abrasions (scrape that is bleeding) - CORRECT ANSWERS List examples of open wounds Closed wound - CORRECT ANSWERS ·results from a blow, force, or strain caused by trauma such as a fall, an assault, or car crash. Skin surface is not broken, but soft tissue is damaged underneath the epidermis Internal injury and hemorrhage may occur ecchymosis and hematomas (look like bruises) - CORRECT ANSWERS List examples of closed wound ecchymosis - CORRECT ANSWERS Broken surface capillary under the skin is bleeding Hematoma - CORRECT ANSWERS A collection of blood under the skin, deeper injury (like a hard lump of blood) Acute wound - CORRECT ANSWERS Heal within days to weeks. Normal healing process (no interruption) The wound edges meet to close skin surface; risk of infection is low
Surgical incisions - CORRECT ANSWERS An example of an acute wound is__________ Increased granulation tissue - CORRECT ANSWERS A nurse is providing care for a patient who is malnourished with the nursing diagnosis of impaired tissue integrity r/t an acute open wound. The nurse correctly select which outcome as the most appropriate to demonstrate wound healing? tissue necrosis - CORRECT ANSWERS A nurse is assessing the wound bed of a patient's acute open wound. The nurse correctly identifies the yellow stringy tissue as: Chronic wounds - CORRECT ANSWERS do not progress through the normal sequence of repair normal healing time is delayed (> 30 days) the inflammatory phase - CORRECT ANSWERS What phase of healing do chronic wounds remain in? wounds r/t diabetes, arterial or venous insufficiency, and pressure injuries - CORRECT ANSWERS Examples of chronic wounds Decreased and dark (amber) - CORRECT ANSWERS A nurse is providing care for an older adult patient that is currently dehydrated. What does the nurse anticipate regarding the patient's urine output and color? kidneys reabsorbing fluid - CORRECT ANSWERS The nurse understands the reason for the decreased urine output and concentrated urine color is the result of what? carbs, proteins, and fats (proteins are the most important) - CORRECT ANSWERS What are the energy rich nutrients to promote healing? They will become compromised and breakdown. Placing the patient at an increased risk for injury - CORRECT ANSWERS If the patient does not receive energy rich nutrients, what may happen?
malnutrition - CORRECT ANSWERS When assessing the patient's lab values r/t urine output, the nurse notes a BUN and Creatine level below normal limits. The nurse correctly identifies the patient's nutritional status as what? Partial thickness - CORRECT ANSWERS where all or a portion of the dermis is intact FUll-thickness - CORRECT ANSWERS entire dermis is gone (exposed bone, tendon, or muscle) unstageable - CORRECT ANSWERS a full-thickness loss where the true depth cannot be determined; may also involve deep tissue injury usually tunneling, necrosis, slough Wound healing - CORRECT ANSWERS •A process of tissue response to injury. •Normally occurs without assistance. •Occurs by primary, secondary, or tertiary intention. Primary intention - CORRECT ANSWERS Type of intention: Well approximated wound edges (surgical incision). Secondary intention - CORRECT ANSWERS Type of intention rough wound edges, require more tissue replacement, often contaminated. •Traumatic, unplanned
cough or sneeze - CORRECT ANSWERS With secondary intention, a patient could ______ or _______ and it could open up Tertiary intention - CORRECT ANSWERS Type of intention: •wounds left open for several days for therapeutic reasons, and then are closed. •Large dehiscence, huge stage IV ulcer It will heal by secondary intention (from the base upwards) Healing time and scar tissue will be increased - CORRECT ANSWERS What happens if a wound healing by primary infection becomes infected? What will result in terms of healing time and scar tissue?
•Exudate results causing pain and swelling. •Clot loses fluid and a hard scab is formed to protect the injury. exudate - CORRECT ANSWERS this is the outward drainage and it forms the scab It delays the formation of a blood clot - CORRECT ANSWERS How would a medication like a blood thinner (anticoagulant) do to affect wound healing phase of hemostasis? longer - CORRECT ANSWERS A nurse is planning education for a patient recently prescribes a blood thinner. The nurse understands it is most important to inform the patient that bleeding times will be: about 2-3 days - CORRECT ANSWERS How long does the inflammatory phase last? inflammatory phase - CORRECT ANSWERS WBCs move to the wound Leukocytes arrive first; macrophages 24 hours later Acute inflammation = pain, heat, redness, swelling at site of injury Leukocytes - CORRECT ANSWERS Inflammatory phase: _______________ arrive first and ingest bacteria and cellular debris. Macrophages - CORRECT ANSWERS Inflammatory phase: ____________________ arrive 24 hours later and release growth factors which attracts fibroblasts (fill in the wound).
Inflammatory phase - CORRECT ANSWERS In this phase, the patients response is mildly elevated temp, leukocytes, and malaise Production of WBCs and release of growth factors are inhibited at the cellular level due to chronic medical conditions - CORRECT ANSWERS Chronic wounds are stuck in inflammation phase? Why is this? for several weeks - CORRECT ANSWERS How long does the proliferation phase last? Proliferation phase - CORRECT ANSWERS •New tissue is built to fill the wound space, through the action of fibroblasts. •New tissue is referred to as granulation tissue (vascular and bleeds easily). •Granulation tissue forms the foundation for scar tissue development. Adequate nutrition, oxygenation, and prevention of strain on the suture line - CORRECT ANSWERS What is important to consider when in the proliferation phase? -Formation of granulation tissue will be delayed -They need nutrition and oxygenation (a good blood supply) - CORRECT ANSWERS What should the nurse expect regarding the proliferation phase of wound healing for a nutritionally compromised (not enough nutrition) patient? Maturation - CORRECT ANSWERS What is the final stage of wound healing? 3 weeks after the injury (may continue for months or years) - CORRECT ANSWERS When does the maturation phase begin? Maturation phase - CORRECT ANSWERS •Collagen is restructured and scar tissue is formed.
•Scar tissue is less elastic than normal tissue (becomes flat) incision - CORRECT ANSWERS · Cutting or sharp instrument; wound edges in close approximation and aligned contusion - CORRECT ANSWERS Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma abrasion - CORRECT ANSWERS ·Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded laceration - CORRECT ANSWERS · Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue puncture - CORRECT ANSWERS Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental penetrating - CORRECT ANSWERS Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues Avulsion - CORRECT ANSWERS Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures (part of the body has fallen off) chemical wound - CORRECT ANSWERS Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis thermal wound - CORRECT ANSWERS High or low temperatures; cellular necrosis as a possible result Irridation - CORRECT ANSWERS · Ultraviolet light or radiation exposure
pressure ulcer, venous ulcer, arterial ulcer, diabetic ulcer - CORRECT ANSWERS List the chronic wounds. Pressure Ulcers - CORRECT ANSWERS Compromised circulation secondary to pressure or pressure combined with friction Venous ulcers - CORRECT ANSWERS Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction arterial ulcers - CORRECT ANSWERS · Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis (clots) diabetic ulcers - CORRECT ANSWERS injury and underlying diabetic neuropathy (nerve damage), peripheral arterial disease, diabetic foot structure intact skin - CORRECT ANSWERS The first line of defense is _______
temp, heart and respiratory rates, anorexia or nausea and vomiting, musculoskeletal tension, and hormonal changes - CORRECT ANSWERS What can a surgical incision cause? · An adequate blood supply is essential · Normal healing is promoted when wound is free of foreign material · The body's response to a wound is more effective if proper nutrition has been maintained - CORRECT ANSWERS Principles of wound healing Local factors Systematic factors - CORRECT ANSWERS Factors affecting wound healing
local - CORRECT ANSWERS factors that occur directly on the wound, not related to the wound itself systematic - CORRECT ANSWERS factors that occur throughout the body
Requires a lot of energy from the body, results in delayed wound healing Necrosis - CORRECT ANSWERS Local factor: Dead tissue (yellow, stringy, sloughy, black) in wound bed, results in delayed healing Biofilm - CORRECT ANSWERS Local factor: Wound bacteria that grows in thick clumps, results in delayed healing
Nutritonal status - CORRECT ANSWERS Systematic factor: •Protein deficiency, lack of Vitamins A and C impacts all phases of wound healing. Medications - CORRECT ANSWERS Systematic factor: •Corticosteroids (decrease inflammation process), prolonged antibiotics (increased risk for superinfection), and immunosuppressive medications (halts the proliferation phase). Vitamin A and C (and high protein) - CORRECT ANSWERS What vitamins do you need to help heal a wound?
increased white blood cell count delayed healing discoloration - CORRECT ANSWERS Symptoms of an infection hemorrage - CORRECT ANSWERS may occur from a slipped suture, a dislodged clot at the wound site, infection, or erosion of a blood vessel by a foreign body a hematoma - CORRECT ANSWERS What does an internal hemorrhage cause the formation of? Dehiscence and evisceration - CORRECT ANSWERS the most serious postoperative wound complications a medical emergency- treat like an open wound Dehiscence - CORRECT ANSWERS the partial or total separation of wound layers that are not healed evisceration - CORRECT ANSWERS the most serious complication of dehiscence. Occurs with abdominal incisions. The abdominal wound completely separates, with protrusion of viscera (internal organs) through the incisional area abdominal surgery obese or malnourished smoke tobacco
use anticoagulants infected wounds excessive coughing, vomiting, straining - CORRECT ANSWERS Who is at greater risk for dehiscence and evisceration •Increase amount of serosanguineous fluid from the wound 4-5 days post up. •Patient might say something like, "something has suddenly given away". - CORRECT ANSWERS What are the signs of dehiscence and evisceration? Assess & call physician - CORRECT ANSWERS Dehiscence and Evisceration- What is the first action? sterile towels moistened with sterile 0.9% NSS. - CORRECT ANSWERS With evisceration, what should you cover the area with? Place in low Fowler's position (this places less pressure on the wound) and call physician ASAP. - CORRECT ANSWERS Dehiscence and Evisceration- What position do you place the patient in? Fistula formation - CORRECT ANSWERS an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another. May be created purposefully, or as the result of an infection that has developed into an abscess. It > the risk for delayed healing, fluid and electrolyte imbalance Pressure injury (ulcer) - CORRECT ANSWERS ·Localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is r/t use of a medical device
mental status and age - CORRECT ANSWERS Basic risk factor list for pressure injury development · Inadequate nutrition and dehydration, skin moisture, altered mental status, and advanced age · Poor skin hygiene · Diabetes mellitus · Diminished sensory perception (pain awareness) · Fractures · History of corticosteroid therapy · Immunosuppression · Increased body temperature · Microvascular dysfunction · Multiple organ dysfunction syndrome (MODS) · Previous pressure injuries · Significant obesity or thinness · Terminal illness/end-of-life/dying process - CORRECT ANSWERS Risk factors for pressure injury development: swollen and deep red, hot on palpation - CORRECT ANSWERS When an infection is present the wound is ______ drainage - CORRECT ANSWERS ·The inflammatory response results in formation of exudate which then drains from the wound fluid and cells that escape from blood vessels and deposited in or on tissue surfaces - CORRECT ANSWERS what is the exudate composed of? serous drainage - CORRECT ANSWERS composed primarily of the clear, serous portion of the blood and from serous membranes.
clear and watery. Sanguineous drainage - CORRECT ANSWERS consists of large numbers of red blood cells and looks like blood. Bright-red drainage is indicative of fresh bleeding darker drainage indicates older bleeding. Serosanguineous drainage - CORRECT ANSWERS a mixture of serum and red blood cells. It is light pink to blood tinged. Purulent drainage - CORRECT ANSWERS made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Pressure injury staging - CORRECT ANSWERS Classified according to 6 stages. 4 numbered and 2 unnumbered. Stage I, Stage II, Stage III, Stage IV, unstageable, and deep tissue pressure injury. Stage 1 Pressure Injury: Nonblanchable Erythema of Intact Skin - CORRECT ANSWERS Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
Color changes do not include purple or maroon discoloration Stage 2 Pressure Injury: Partial-Thickness Skin Loss With Exposed Dermis - CORRECT ANSWERS Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. Stage 2 Pressure Injury: Partial-Thickness Skin Loss With Exposed Dermis - CORRECT ANSWERS These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-Thickness Skin Loss - CORRECT ANSWERS Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (black looking scab) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur.
Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss - CORRECT ANSWERS Full- thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. Unstageable Pressure Injury. - CORRECT ANSWERS Extent of tissue damage cannot be determined due to slough or eschar. Deep tissue pressure injury - CORRECT ANSWERS nonblanchable purple or maroon discoloration of intact or nonintact skin. May be firm, mushy, or boggy feeling. stage II - CORRECT ANSWERS After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, the pressure injury would be classified as: stage I - CORRECT ANSWERS Intact with area of nonblanchable erythema. Stage II - CORRECT ANSWERS Break in the epidermis with exposed dermis. Stage IV - CORRECT ANSWERS Full thickness tissue loss with visible tendon. skin assessment - CORRECT ANSWERS Systematically; head-to-toe Include bony prominences
On admission and then at regular intervals acute care - CORRECT ANSWERS On admission, then every shift and with any changes in condition long-term care - CORRECT ANSWERS On admission, then reassess weekly for 4 weeks, then quarterly and with any changes in condition home health care - CORRECT ANSWERS On admission, then reassess at every visit appearance, odor, drainage, pain - CORRECT ANSWERS Wound assessment involves inspection of: pain - CORRECT ANSWERS ◦Determines the status of the wound ◦Identifies barriers to the healing process ◦Identifies signs of complication ◦Note the location in relation to the nearest anatomic landmark ◦Document the size of the wound ◦Assess for approximation of wound edges (do edges meet?) and signs of dehiscence or evisceration ◦Assess the color of the wound and surrounding skin ◦Assess for the presence of odor (Pseudomonas aeruginosa - sweet; Proteus - ammonia like)