Skin Integrity

  1. What are some factors that affect skin integrity?
    • —Genetics and heredity
    • —Age
    • —Chronic illnesses and their treatments
    • —Medications
    • —Poor nutrition
  2. Risk factors for pressure ulcers are:
    • —Advanced age
    • —Chronic mental conditions
    • —Poor lifting and transferring techniques
    • —Incorrect positioning
    • —Hard support surfaces
    • —Incorrect application of pressure-relieving devices
  3. The picture below is an example of what stage pressure ulcer.
    Image Upload 2
    Stage 1 ulcer
  4. Factors that affect wound healing include:
    • —Age
    • —Nutritional status
    • —Lifestyle
    • —Medications
  5. The treatments for pressure ulcer:
    • —Minimize direct pressure
    • —Schedule and record position changes
    • —Provide devices to reduce pressure areas
    • —Clean and dress the ulcer using surgical asepsis
    • —Never use alcohol or hydrogen peroxide
    • —Obtain C&S, if infected
    • —Teach the client
    • —Provide ROM exercise
  6. What can promote healing & prevent pressure ulcer complications?
    • —Fluid intake
    • —Protein, vitamin, and zinc intake
    • —Dietary consult
    • —Nutritional supplements
    • —Monitor weight/lab values
    • —Prevent entry of microorganisms
    • —Prevent transmission of pathogens
  7. True or False.
    Any client experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development.
  8. ______ the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface.
  9. The force of two surfaces moving across one another, such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens is called ____.
  10. True or False.
    Moisture reduces the skin's resistance to other physical factors such as pressure and/or shear force.
  11. Identify the stage pressure ulcer being described based on the information given below:
    Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
    Stage II pressure ulcer
  12. Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. This is a _____ pressure ulcer.
    Stage III
  13. A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by ______.
    Secondary intention
  14. Wounds that are contaminated and require observation for signs of inflammation heal by______.
    Tertiary intention
  15. _____ is a localized collection of blood underneath the tissues.
    A hematoma
  16. What type of wound drainage is seen below and give some characteristics of it:

    Image Upload 4
    This is a purulent type of wound drainage. Typically purulent wound drainage is thick, yellow, green, tan, or brown in appearance.
  17. A score of 14 or less on the Norton scale indicates ______.
    Risk of pressure sore development
  18. A low score on the Braden scale indicates ____.
    A high risk for pressure sore development
  19. When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating:
    1.A local skin infection requiring antibiotics
    2.This client has sensitive skin and requires special bed linen
    3.A stage III pressure ulcer needing the appropriate dressing
    4.Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area
    The correct is #
  20. This type of pressure ulcer has an observable pressure-related alteration of intact skin whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching).

    1.Stage I
    2.Stage II
    3.Stage III
    4.Stage IV
    The correct answer is # 1
  21. Postoperatively the client with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to:

    1. Allow the area to be exposed to air until all drainage has stopped
    2. Place several cold packs over the areas, protecting the skin around the wound
    3. Cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
    4. Cover the area with sterile gauze, place a tight binder over the areas, and ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
    The correct answer is #
  22. Serous drainage from a wound is defined as:

    1.Fresh bleeding
    2.Thick and yellow
    3.Clear, watery plasma
    4.Beige to brown and foul smelling
    The correct answer is #
Card Set
Skin Integrity
Nursing 200 Skin Integrity topic