tissue integrity

Question 1

braden scale

Answer 1

sensory perception
moisture
mobility
nutrition
friction and shear
higher # is better!

Question 2

RYB

Answer 2

red-> cover
yellow-> clean
black-> debridement/remove dead tissue

Question 3

intrinsic factors

Answer 3

immobility
impaired sensation
malnourishment
age

Question 4

extrinsic factors

Answer 4

friction
pressure
sheering
exposure to moisture

Question 5

pressure injury staging

Answer 5

stage 1-> nonblanchable erythema of intact skin
stage 2-> partial-thickness skin loss with exposed dermis
stage 3-> full-thickness skin loss
stage 4-> full-thickness and tissue loss

Question 6

unstageable and DTPI

Answer 6

unstageable->obscured full-thickness and tissue loss
deep tissue pressure injury (DTPI)-> persistent nonblanchable deep red, maroon, or purple discoloration

Question 7

TIME

Answer 7

T- tissue integrity
I- inflammation/infection
M- moisture
E- edge of wound

Question 8

macule

Answer 8

flat and colored
smaller than 1 cm
freckles

Question 9

papule

Answer 9

elevated and raised
superficial
elevated nevus

Question 10

nodule

Answer 10

wart

Question 11

pustule

Answer 11

elevated
filled with puss
acne

Question 12

tumor

Answer 12

solid mass

Question 13

wheal

Answer 13

elevated
superficial
localized edema
insect bite

Question 14

atrophy

Answer 14

thinning of the skin

Question 15

exoriation

Answer 15

superficial

Question 16

erosion

Answer 16

loss of superficial epidermis

Question 17

fissure

Answer 17

linear break in skin

Question 18

ulcer

Answer 18

irregular shape, loss of tissue

Question 19

crust

Answer 19

elevated, rough texture

Question 20

scales

Answer 20

white/tan flaking skin cells

Question 21

scar

Answer 21

fibrous tissue at site of injury

Question 22

factors influencing wound healing

Answer 22

D- diabetes
I- infection
D- drugs
N- nutritional problems
T- tissue necrosis
H- hypoxia
E- extensive tension
A- another wound
L- low temps

Question 23

wound drains

Answer 23

penrose
bulb suction device
large bottle drain
circular portable wound suction device

Question 24

types of wound healing

Answer 24

primary intention-> closed with skin adhesives, sutures (surgical incisions)
secondary intention-> left open to heal (pressure injury, burns)
delayed intention-> combo of 1st and 2nd open 5-10 days-> closed with sutures

Question 25

hemostatic/inflammatory phase

Answer 25

the damaged tissue releases cytokines which trigger a process called hemostasis; blood coagulates, and the wound starts to heal plasma leaks into surrounding tissue and causes swelling 3-6 days long

Question 26

proliferative phase

Answer 26

new collagen fibers are formed, a new wound bed is created and capillaries start growing the wound edges begin pulling closer and new granulation tissue grows 3-24 days

Question 27

remodeling phase

Answer 27

stronger collagen replaces the soft gelatinous collagen; however, this tissue is much weaker than the original tissue and is susceptible to re-injury (occurs on about day 21, can take more than 1 year to complete)

Question 28

wound healing complications

Answer 28

infection dehiscence eviceration bleeding-hemorrhage fistula

Question 29

exudate

Answer 29

drainage serous-straw color serosanguineous-straw color and blood sanguineous-bloody purulent-puss purosanguineous-puss and blood

Question 30

films

Answer 30

superficial wounds minimal exudate allows moisture to evaporate maintains moist wound bed allows visualization without removal

Question 31

hydrocolloid dressings

Answer 31

small abrasions burns pressure injuries post-op wounds gel-like bacteriostatic properties maintain moist wound bed stimulate growth of granulation tissue

Question 32

alignate dressings

Answer 32

moderate-highly exudative wounds provides hemostasis high absorbency less frequent changes secondary dressing needed

Question 33

hydrofiber dressings

Answer 33

used for moderate-highly exudative wounds high absorbency draws less fluid from wound edges

Question 34

foams

Answer 34

mild-moderate exudate more frequent changes helps prevent HAPIs

Question 35

polymeric membranes

Answer 35

mildy exudative wounds stimulate epithelial growth does not stick to wound bed

Question 36

hydrogels

Answer 36

gel/sheet form soothing/cooling effect contains water manage dry wound for debridement of necrotized tissue