NUR 201 Skin Integrity & Wound Care EXAM REVIEW QUESTIONS MULTIPLE CHOICES WITH CORRECT DETAILED ANSWERS.

Learning objectives: 1. Discuss the risk factors that contribute to pressure injury formation. 2. Describe the pressure injury staging system. 3. Discuss the normal process of wound healing. 4. Describe the differences in wound healing by primary and secondary intention. 5. Explain the factors that impede or promote wound healing. 6. Describe the differences between nursing care of acute and chronic wounds. 7. Complete an assessment for a client with impaired skin integrity. 8. Develop a nursing care plan for a client with impaired skin integrity. 9. Use critical thinking to when providing care to clients at risk for or with actual impaired skin integrity. - correct answer ... Study Guide Review Questions: - What are some factors that can cause skin breakdown? - What nutritional factors relate to skin integrity (why do we give supplements?) - Think critically about preparing and maintaining sterile field (you did this in lab). Why is sterile technique used? If anything in the field touches something that is not sterile, what would you do? - Know the phases of wound healing what you would see on assessment in each phase. What things would you see to indicate the wound is healing? - What are nursing interventions to promote skin integrity and prevent skin breakdown? - Describe the 4 wound stages and what you would see on assessment. - If there is necrotic tissue in the wound bed how could it be treated? - correct answer ... What are some factors that can cause skin breakdown? (6 answers) - correct answer 1. Impaired sensory perception 2. Impaired mobility 3. Alteration in LOC (level of consciousness) 4. Shear 5. Friction 6. Moisture What nutritional factors relate to skin integrity (why do we give supplements?) - correct answer - Important nutritional components related to healing are calories, protein, vitamins A and C, and minerals zinc and copper - Vitamin C is the most important vitamin to have because collagen can maintain your skin's structure and integrity - Hydration plays a vital role in the preservation and repair of skin integrity Why is sterile technique used? If anything in the field touches something that is not sterile, what would you do? - correct answer - In health care, sterile technique is always used when the integrity of the skin is accessed, impaired, or broken (free of infection) - If something is contaminated, you have to throw it away and get a new clean unused equipment Define Primary intention - correct answer - After a surgical incision in which the edges of the wound are connected by a suture - Heals quickly, risk for infection low Define secondary intention - correct answer - A wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally - Takes longer to heal, risk for infection greater Define Tertiary intention - correct answer - The intentional delay in closing a wound. On occasion, wounds are left open (covered by a sterile dressing) to allow an infection or inflammation to subside Arrange the phases involved in the process of a Partial-thickness wound repair in the correct order. 1. epithelial proliferation 2. reestablishment of the epidermal layers 3. inflammatory response 4. migration - correct answer 3. inflammatory response 1. epithelial proliferation 4. migration 2. reestablishment of the epidermal layers Arrange the phases involved in the process of a full-thickness wound repair in the correct order. 1. Hemostasis 2. Remodeling 3. Proliferative phase 4. Inflammatory phase - correct answer 1. Hemostasis: (body activates its emergency repair system to form a dam to block the drainage and prevent too much blood loss, clotting) 4. Inflammatory phase: (injured blood vessels leak transudate [made of water, salt, and protein] causing localized swelling, controls bleeding and prevents infection) 3. Proliferative phase: (wound is rebuilt with new tissue made up of collagen and extracellular matrix) 2. Remodeling: (collagen synthesis is ongoing in order to strengthen the tissue) The nurse assesses a client's abdominal wound and finds that the wound is in the proliferative phase of healing. Which changes in the wound might have led the nurse to this conclusion? Select all that apply: A. The wound is filled with granulation tissue. B. There is localized redness, edema, warmth, and throbbing. C. The wound contracts to reduce the area that requires healing. D. There is vasodilation of the surrounding capillaries, and exudation of serum. E. There is reepithelialization of the wound surface. - correct answer A. The wound is filled with granulation tissue. C. The wound contracts to reduce the area that requires healing. E. There is reepithelialization of the wound surface. Describe the differences between nursing care of ACUTE and CHRONIC WOUNDS - correct answer Acute: - Wound heals promptly and without complications; easily cleaned and repaired - Needs immediate intervention; require close monitoring - Usually trauma, a surgical incision Chronic: - Course of treatment is lengthy and costly - Stable, but difficult to heal - Uses clean technique What are some complications of wound healing? (4 answers) - correct answer 1. Hemorrhage 2. Infection 3. Dehiscence 4. Evisceration What factors influence pressure injury formation and wound healing? (5 answers) - correct answer 1. Nutrition 2. Tissue perfusion 3. Infection 4. Age 5. Psychosocial impact of wounds Describe the 4 wound stages and what you would see on assessment. - correct answer Stage 1: - Non-blanchable erythema of intact skin - Skin discoloration, warmth, edema, hardness, or pain Stage 2: - Partial-thickness skin loss with exposed dermis - Shiny or dry shallow open ulcer with red-pink wound bed Stage 3: : - Full-thickness skin loss (fat visible) - Subcutaneous fat may be visible; but bone, tendon, or muscle is not exposed Stage 4: - Full-thickness skin and tissue loss (Muscle/Bone Visible) What are nursing interventions to promote skin integrity and prevent skin breakdown? (5 answers) - correct answer 1. Decreased sensory perception: - Assess pressure points for signs of nonblanching reactive hyperemia 2. Moisture: - Protect skin with moisture-barrier ointment 3. Friction and shear: - Reposition patient using drawsheet and lifting off surface 4. Decreased activity/mobility: - Establish individualized turning schedule. 5. Poor nutrition: - Provide adequate nutritional and fluid intake; assist with intake as necessary If there is necrotic tissue in the wound bed how could it be treated? - correct answer - Autolytic debridement: Autolytic debridement leads to softening of necrotic tissue. It can be accomplished using dressings that add or donate moisture - This method uses the wound's own fluid to break down necrotic tissue - Semi-occlusive or occlusive dressings are primarily used A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six sub scales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long-term care facility using for risk assessment of pressure injury development? A. Gaskin's Nursing Assessment of Skin Color (GNASC) tool B. Braden scale C. Bates-Jensen Wound Assessment Tool (BWAT) D. Wound, Ostomy, and Continence Nurses Society (WOCN) scale - correct answer B. Braden scale Which criteria does the Braden Scale Evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk of pressure injury C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk of poor wound healing - correct answer B. Risk factors that place the patient at risk of pressure injury Which finding is characteristic of a stage 3 pressure injury? Select all that apply: A. It has full-thickness skin loss B. The subcutaneous fat may be visible C. The wound may present as an open, serum-filled blister D. There may be a reddish-pink wound bed without slough E. Neither the bone, tendon, nor muscle is exposed - correct answer A. It has full-thickness skin loss B. The subcutaneous fat may be visible E. Neither the bone, tendon, nor muscle is exposed The nurse understands that a protein deficiency can adversely affect wound healing. Which parameter should be measured to determine this deficiency in this patient? Select all that apply: A. Serum albumin B. Serum transferrin C. Serum prealbumin D. Hemoglobin levels E. Serum creatinine levels - correct answer A. Serum albumin B. Serum transferrin C. Serum prealbumin What terms are used to describe impaired skin integrity related to prolonged, unrelieved pressure on a body part? Select all that apply. A. Skin tag B. Bedsore C. Skin wound D. Pressure sore E. Pressure ulcer F. Decubitus ulcer - correct answer B. Bedsore D. Pressure sore E. Pressure ulcer F. Decubitus ulcer Which vitamins should be provided to the client to promote wound healing? Select all that apply: A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D E. Vitamin E - correct answer A. Vitamin A C. Vitamin C