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Skin Integrity & Wound Care Flashcards | StudBud
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Skin Integrity & Wound Care
Skin Integrity & Wound Care
42 terms
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StudBud Administration
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Lets review our lecture on #skinintegrity and how to assess #woundcare
Flashcards
42 cards
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Practice quiz
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Questions
42
Answers
1
What would you stage a pressure ulcer described as partial-thickness open ulcer?
Stage II
Stage IV
Stage I
Stage III
2
This wound would be classified as a:
Stage I pressure ulcer
Stage III pressure ulcer
Stage IV pressure ulcer
Stage II pressure ulcer
3
Unstageable pressure ulcer is identified mostly because
the base is covered with slough, wound bed is still visible
skin is intact and its the color of purple/maroon
muscle is exposed and the wound of the bed is visible
the base is covered with eschar, wound bed is not visible
4
In Suspected Deep Tissue Injury (sDTI)
Skin intact and Purple or maroon localized area discolored
Commonly found on the sacrum and heels
Patients with a sDTI are usually older
All of the Above
5
Evisceration can be described as...
Extrusion of viscera outside of body
Rupture of the wound bed
Tearing apart of the edges of a wound bed
Premature closure of the wound bed
6
Important labs to look at for wound healing include protein and albumin
False
True
7
the elderly should take special care with their skin
False
True
8
Psoriasis is what kind of disorders?
Age related
Pediatric
Psychological
Autoimmune
9
Transparent film dressings can be used for:
skin tears in elderly patients
promoting healing
minor pressure injuries and wounds
all the above
10
Wich dressing is appropriate to prevent pressure injury
wet to dry
transparent
silicon foam
calcium alginate
11
Pallor can be described as...
persistent
palpable
pale
warm
12
pressure injury
Unstageable
Wound base is covered in slough and/or eschar (necrotic tissue)
unknown depth
red/moist base
Open wound, visible adipose tissue.
13
Melanoma occurs when abnormal skin cells divide uncontrollably. This is called
dynamic equilibrium
cancer
homeostasis
melanogens
14
Stage 4 Pressure Injury:
Full thickness tissue loss. May be fully covered with eschar
Full thickness tissue loss with bone/tendon/muscle exposed.
Full thickness tissue damage without bone/tendon exposed
Full thickness tissue loss. May be fully covered with slough
15
Why is it so important for patients to have adequate nutrition for proper wound healing?
Fluid is needed to hydrate skin and promote perfusion
Protein is needed to repair the skin & promote healing
Adequate nutrition promotes healthy immunity
All of the above
16
Which stage of wound healing is characterized by clotting of the wound and fibrin deposits?
Proliferative Phase
Hemostasis
Inflammatory Phase
Maturation
17
Wound irrigation is considered what type of debriedment?
Enzymatic
Autolytic
Surgical
Mechanical
18
suspected deep tissue injuries are what color?
bright red
pink
maroon/purple
black
19
Stage 3 Pressure Injury:
Partial thickness skin loss. May be shallow or open wound
Full thickness tissue loss. Some slough, but no bone/tendon
Partial thickness loss of dermis. May have slough, minimal.
Full thickness tissue loss. Bone/tendon may be exposed
20
Which type of drainage would be described as pink-yellow?
Serous
Serosanguinous
Sanguineous
Purulent
21
Albumin helps with healing ability.
True
False
22
Proper care for elderly with dry skin include all but
apply lotion
use mild soap
give sponge baths
use hot water
23
The Braden Scale assesses all of the following
EXCEPT
?
Nutrition
Moisture
Sensory
Comorbidities
24
Gauze dressings range from plain gauze to impregnated gauze
True
False
25
These dressings are highly absorbent and useful for wounds with copious exudate
Hydrogel
Hydrofiber
Transparent Film
Alginate
26
skin cancer includes malignant melanomas, basal cell carcinoma and ...
squamous cell carcinomas
squamous cell melanomas
square cell carcinomas
malignant cell carcinomas
27
Stage 2 Pressure Injury:
Partial thickness skin loss. Can have slough, but minimal
Full thickness tissue loss with or without slough (minimal)
Full thickness tissue loss with no slough or eschar.
Partial thickness skin loss without any slough.
28
What is true of psoriasis?
It results in the eruption of red vesicles
It is usually red and bumpy and found on the cheeks, upper arms, or thighs
It results from sun damage
It is usually found in patches on the scalp, elbows, knees, chest, low back
29
Silicone foam dressings may be used prophylactically for pressure injury prevention?
True
False
30
Gauze dressings:
absorb drainage
Keep the wound moist
Allow observations of the wound
Have a non-stick surface
31
Hydrocolloid dressings...
all of the above
are used for moist wound healing
are contraindicated for infected wounds
offer NO air exchange
32
This wound is healing by:
Secondary intention
Tertiary intention
None of the above
Primary intention
33
What is a Tegaderm or transparent dressing?
Exposes the center of the wound, allowing air to reach it
Prevents visualization the wound
Self-adhesive transparent barrier
Adheres to damaged skin
34
What is a characteristic of psoriasis?
flat, nonpalpable changes in skin color like maculae/patches
subcutaneous tumors filled with sebum
benign outgrowths of the skin that look like flaps
red patches covered with white-silver scales
35
Hydrogel dressing provides
an absorbent surface to collect wound drainage
moisture needed for wound healing.
decreased incidence of skin maceration.
protection from the external environment.
36
Foul smelling drainage is indicative of ____.
Infection
Sinus tract
Proper healing
Tunneling
37
A Hydrogel Dressing ...
used as a primary dressing and requires a secondary dressing
usually used for wound with nil or low levels of exidate
semi- permeable, transparent and flexible dfressing
acts as a debriding agent by softening dead tissue
38
Copious serous exudate indicates what type of ulcer?
Arterial
Venous
39
What needs to be removed in order to stage an unstageable pressure ulcer?
Pustules and vesicles
Slough and eschar
Maggots
Hair
40
Montgomery straps are used in patients who...
Require 24 hour monitoring d/t delayed wound healing
Require frequent dressing changes
Are obese and difficult to secure dressing to
Are allergic to adhesives
41
Risk factor of melanoma?
High sodium diet.
History of blistering sunburns.
People of Asian descent.
Obesity.
42
Thick yellow wound drainage with a foul odor would be documented as
sanguinous
serosanguinous
serous
purulent
