Chapter 48 - Skin Integrity and Wound Care proctored exam complete solutions 100% verified answers graded a+.

Epidermis - correct answer e. Top layer of the skin Dermis - correct answer f. Inner layer of the skin that provides tensile strength and mechanical support Collagen - correct answer a. Tough, fibrous protein Pressure ulcer - correct answer b. Localized injury to the skin and underlying tissue over a body prominence Blanching - correct answer d. Normal red tones of light-skinned patients are absent Darkly pigmented skin - correct answer c. Does not blanch Identify the pressure factors that contribute to pressure ulcer development. (3) - correct answer a. Pressure intensity b. Pressure duration c. Tissue tolerance Identify the risk factors that predispose a patient to pressure ulcer formation. (6) - correct answer a. Impaired sensory perception b. Impaired mobility c. Alteration in level of consciousness d. Shear e. Friction f. Moisture Staging systems for pressure ulcers are based on he depth of tissue destroyed. Briefly describe each stage. Stage I - correct answer Stage I. Intact skin with nonblanchable redness of a localized are over a bony prominence Staging systems for pressure ulcers are based on he depth of tissue destroyed. Briefly describe each stage. Stage II - correct answer Stage II. Partial-thickness skin loss involving epidermis, dermis, or both Staging systems for pressure ulcers are based on he depth of tissue destroyed. Briefly describe each stage. Stage III - correct answer Stage III. Full-thickness with tissue loss Staging systems for pressure ulcers are based on he depth of tissue destroyed. Briefly describe each stage. Stage IV - correct answer Stage IV. Full-thickness tissue loss with exposed bone, tendon, or muscle Define the following terms related to wound healing. Granulation tissue - correct answer Red, moist tissue composed of new blood vessels, which indicates wound healing Define the following terms related to wound healing. Slough - correct answer Stringy substance attached to wound bed that is soft, yellow, or white tissue Define the following terms related to wound healing. Eschar - correct answer Black or brown necrotic tissue Define the following terms related to wound healing. Exudate - correct answer Describes the amount, color, consistency, and odor of wound drainage Describe the physiological process involved with would healing. Primary intention - correct answer Wound that is closed by epithelialization with minimal scar formation Describe the physiological process involved with would healing. Secondary intention - correct answer Wound is left open until it becomes filled by scar tissue; chance of infection is greater Identify the three components involved in the healing process of a partial-thickness wound. (3) - correct answer a. Inflammatory response b. Epithelial proliferation (reproduction) c. Migration with reestablishment of the epidermal layers Explain the four phases involved in the healing process of a full-thickness wound. Hemostasis - correct answer Injured blood vessels constrict, and platelets gather to stop bleeding; clots form a fibrin matrix for cellular repair Explain the four phases involved in the healing process of a full-thickness wound. Inflammatory phase - correct answer Damaged tissues and mast cells secrete histamine (vasodilates) with exudation of serum and WBC into damaged tissues Explain the four phases involved in the healing process of a full-thickness wound. Proliferative phase - correct answer With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization. Explain the four phases involved in the healing process of a full-thickness wound. Remodeling - correct answer Maturation, the final stage, may take up to I year; the collagen scar continue to reorganize and gain strength for everal months. Briefly explain the following complications of wound healing. Hemorrhage - correct answer Bleeding from a wound site; occurs after hemostasis indicate a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object (internal or external) Briefly explain the following complications of wound healing. Hematoma - correct answer Localized collection of blood underneath the tissue Briefly explain the following complications of wound healing. Health care-associated infection - correct answer Second most common nosocomial infection; purulent material drains from the wound (yellow, green, or brown, depending on the organism) Briefly explain the following complications of wound healing. Dehiscence - correct answer A partial or total separation of wound layers; risks are poor nutritional status, infection, or obesity Briefly explain the following complications of wound healing. Evisceration - correct answer Total separation of wound layers with protrusion of visceral organs through a wound opening requiring surgical repair The Braden Scale was developed for assessing pressure ulcer risks. Identify the subscales of this tool. (6) - correct answer a. Sensory perception b. Moisture c. Activity d. Mobility e. Nutrition f. Friction or shear List the factors that influence pressure ulver formation. (5) - correct answer a. Nutrition b. Tissue perfusion c. Infection d. Age e. Psychosocial impact of wounds Explain the following factors that place a patient at risk for a pressure ulcer. Mobility - correct answer Potential effects of impaired mobility; muscle tone and strength Explain the following factors that place a patient at risk for a pressure ulcer. Nutritional status - correct answer Malnutrition is a major risk factor; a loss of 5% of usual weight, weight less than 90% of lDW, or a decrease of 10 Ib in a brief period Explain the following factors that place a patient at risk for a pressure ulcer. Body fluids - correct answer Continuou exposure of the skin to body fluids, especially gastric and pancreatic drainage, increases the risk for breakdown. Explain the following factors that place a patient at risk for a pressure ulcer. Pain - correct answer Adequate pain control and patient comfort will increase mobility, which in turn reduce risk. Identify the following types of emergency setting wounds. Abrasion - correct answer Is superficial with little bleeding and is considered a partial-thicknes wound Identify the following types of emergency setting wounds. Laceration - correct answer Sometimes bleeds more profusely depending on depth and location (5 cm or 2.5 cm in depth) Identify the following types of emergency setting wounds. Puncture - correct answer Bleed in relation to the depth and size, with a high risk of internal bleeding and infection Explain how the nurse assesses the following. Wound appearance - correct answer Whether the wound edge are closed, the condition of tissue at the wound base; look for complications and skin coloration Explain how the nurse assesses the following. Character of wound drainage - correct answer Amount, color, odor, and consistency of drainage, which depends on the location and the extent of the wound Complete the table below describing the types of wound drainage. Type: Serous Appearance: ? - correct answer Clear, watery plasma Complete the table below describing the types of wound drainage. Type: Purulent Appearance: ? - correct answer Thick, yellow, green, tan or brown Complete the table below describing the types of wound drainage. Type: Serosanguineous Appearance: ? - correct answer Pale, pink, watery; mixture of clear and red fluid Complete the table below describing the types of wound drainage. Type: Sanguineous Appearance: ? - correct answer Bright red; indicates active bleeding Explain how the nurse assesses the following. Drains - correct answer Observe the security of the drain and its location with respect to the wound and the character of the drainage; measure the amount. Explain how the nurse assesses the following. Wound closures - correct answer Surgical wound are closed with staples, sutures, or wound closures. Look for irritation around staple or suture site and note whether the closures are intact. List the potential or actual nursing diagnosis related to impaired skin integrity. (8) - correct answer a. Risk for Infection b. Imbalanced Nutrition: Less than Body Requirement c. Acute or Chronic Pain d. Impaired Skin Integrity e. Impaired Physical Mobility f. Risk for Impaired Skin Integrity g. Ineffective Tissue Perfusion h. Impaired Tissue Integrity List possible goals to achieve wound improvement. (3) - correct answer a. Higher percentage of granulation tissue in the wound base b. No further skin breakdown in any body location c. An increase in the caloric intake by 10% Identify the three major areas of nursing interventions for preventing pressure ulcers. (3) - correct answer a. Skin care