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level: Level 1 of Lesson 11: Skin

Questions and Answers List

level questions: Level 1 of Lesson 11: Skin

QuestionAnswer
Scientific Knowledge Base: Skin: Top layer of skinEpidermis
Scientific Knowledge Base: Skin: Inner layer of skin CollagenDermis
Scientific Knowledge Base: Skin: Separates dermis and epidermisDermal-epidermal junction
Scientific Knowledge Base: Pressure sore, decubitus ulcer, or bed sorePressure ulcers
Scientific Knowledge Base: Pathogenesis:Pressure intensity Pressure duration Tissue tolerance
Scientific Knowledge Base: Pathogenesis: Tissue ischemia BlanchingPressure intensity
Risk factors for pressure ulcer development:Impaired sensory perception Impaired mobility Alteration in LOC Shear Friction Moisture
Classification of Pressure Ulcers: Intact skin with nonblanchable rednessStage 1
Classification of Pressure Ulcers: Partial-thickness skin loss involving epidermis, dermis, or bothStage 2
Classification of Pressure Ulcers: Full-thickness tissue loss with visible fatStage 3
Classification of Pressure Ulcers: Full-thickness tissue loss with exposed bone, muscle, or tendonStage 4
Is a quality of living tissue; it is also referred to as regeneration (renewal of tissuesHealing; Wound healing
Phases of Wound Healing:Inflammatory phase Proliferative phase Maturation phase
Phases of Wound Healing: 1Inflammatory phase
Phases of Wound Healing: 2Proliferative phase
Phases of Wound Healing: 3Maturation phase
Types of wounds: Sharp instrument (e.g. knife or scalpel) Open wound; deep or shallow; once the edges have been sealed together as part of treatment or healing, the incision becomes a closed wound.Incision
Types of wounds: Blow from a blunt instrument Closed wound, skin appears ecchymotic (bruised) because of damaged blood vesselsContusion
Types of wounds: Surface scrape, either unintentional (e.g. scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks) Open wound involving the skinAbrasion
Types of wounds: Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional Open woundPuncture
Types of wounds: Tissues torn apart, often from accidents (e.g., with machinery) Open wound; edges are often jaggedLaceration
Types of wounds: Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments) Open woundPenetrating wound
What intention is this? primary or secondary?Primary intention
What intention is this? primary or secondary?Secondary intention
Types of wound Exudate: 1Serous exudate
Types of wound Exudate: 2Purulent exudate
Types of wound Exudate: 3Sanguineous
Types of wound Exudate: 4Serosanguineous
Types of wound Exudate: 5purosanguineous
Complications of wound healing:Hemorrhage- hematoma Infection Dehiscence Evisceration
Complications of wound healing: 1: Hematomahemorrhage
Complications of wound healing: 2:Infection
Complications of wound healing: 3:Dehiscence
Complications of wound healing: 4:Evisceration
Nursing Knowledge Base: Prediction and prevention of pressure ulcers: Braden scale (refer to your book)Risk assessment
Nursing Knowledge Base: Prediction and prevention of pressure ulcers: Economic consequences of pressure ulcersPrevention
Nursing Knowledge Base: Prediction and prevention of pressure ulcers: Prevention: Medicare and medicaid: no additional reimbursement for care related to stage III and IV pressure ulcers that occur during the hospitalization.Prevention
Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing:Nutrition Tissue perfusion Infection Age Psychosocial impact of wounds
Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 1Nutrition
Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 2Tissue perfusion
Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 3Infection
Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 4Age
Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 5Psychosocial impact of wounds
Nursing process: Through the patient's eyes Skin WoundsAssessment
Nursing process: Assessment: Skin:continually assess skin for signs of breakdown and/or ulcer development
Nursing process: Assessment: Wounds: 1Emergency setting
Nursing process: Assessment: Wounds: 2Stable setting
Nursing process: Assessment: Wounds: 3Wound appearance
Nursing process: Assessment: Wounds: 4Character of wound drainage
Nursing process: Assessment: Wounds: 5Drains
Nursing process: Assessment: Wounds: 6Wound closures
Nursing process: Assessment: Wounds: 7Palpation of wound
Nursing process: Assessment: Wounds: 8: Gram stains BiopsyWound cultures
Risk for infection Imbalanced nutrition: less than body requirements Acute or chronic pain Impaired physical mobility Impaired skin integrity Risk for impaired skin integrity Ineffective peripheral tissue perfusion Impaired tissue integrityNursing Diagnosis
Nursing process: Planning:Goals and outcomes Setting priorities Teamwork and collaboration
Nursing process: Planning: Goals and outcomes: plan interventions according to:Risk for pressure ulcers Type and severity of the wound Presence of complications
Nursing process: Planning: Setting priorities:Preventing pressure ulcers Promoting wound healing
Quick quiz : The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges: A. are approximated B. Migrate across the incision C. appear slightly pink D. slightly overlap each otherAre approximated
Implementation: Health promotion:Prevention of pressure ulcers Topical skin care and incontinence management Positioning Support surfaces
Implementation: Acute care:Dressing Wounds Wound Irrigation and Packing Supporting and Immobilizing Wounds Heat and Cold Applications
Implementation: Dressings:Protects from microorganisms Aids in homeostasis Promotes healing by absorbing drainage or debriding a wound Supports wound site Promotes thermal insulation Provides a moist environment
Implementation: Types of dressings:Gauze Transparent film Hydrocolloid Hydrogel Foam Composite
Implementation: Wound irrigation and packing: Is the washing or flushing out of an area.An irrigation
Implementation: Wound irrigation and packing: is required for a wound irrigation because there is a break in the skin integritySterile technique
Implementation: Supporting and immobilizing wounds:Bandages and binders- serve various purposes A binder
Implementation: Supporting and immobilizing wounds: Is a type of bandage designed for a specific body part; for example, the triangular binder (sling) fits the arm.A binder
Temperature for Hot and Cold Applications: Below 15 degrees Celsius or 59 degrees Fahrenheit Application: Ice bagVery cold
Temperature for Hot and Cold Applications: 15- 18 degrees Celsius or 59-65 degrees Fahrenheit Application: Cold packCold
Temperature for Hot and Cold Applications: 18-27 degrees Celsius or 65 degrees Fahrenheit Application: Cold compressesCool
Temperature for Hot and Cold Applications: 27-37 degrees Celsius or 80-98 degrees Fahrenheit Alcohol sponge bathTepid
Temperature for Hot and Cold Applications: 37-40 degrees Celsius or 98-104 degrees Fahrenheit Warm bath, aquathermia padsWarm
Temperature for Hot and Cold Applications: 40-46 degrees Celsius or 104-115 degrees Fahrenheit Hot soak, irrigations, hot compressionsHot
Temperature for Hot and Cold Applications: Above 46 degrees Celsius or above 115 degrees Fahrenheit Hot water bags for adultsVery hot
Cleaning skin and drain sites: 1: Clean from least contaminated to the surrounding skin Use gentle friction When irrigating, allow the solution to flow from the least to most contaminated areaBasic skin cleaning
Cleaning skin and drain sites:Basic skin cleaning Cleaning skin and drain sites Suture care
Cleaning skin and drain sites: Irrigation- wound irrigationsCleaning skin and drain sites
Cleaning skin and drain sites: Staple removal Suture removalSuture care
Cleaning skin and drain sites: Constant, low-pressure vacuum to remove and collect drainageDrainage evacuation
Quick quiz: A positive patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: A. it has an odor B. A culture is negative C. the edges revel the presence of fluid D. it shows purulent drainage coming from the incision siteD. It shows purulent drainage coming from the incision site
Quick quiz: A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: A. an absorbent surface to collect wound drainage. B. decreased incidence of skin maceration. C. Protection from the external environment D. moisture needed for wound healing.D. moisture needed for wound healing
The skin can only tolerate how much temperature? after that, mapaso nata48.9 degrees Celsius
Rules of 9: Neck and head41%
Rules of 9: Upper trunk9%
Rules of 9: Lower trunk9%
Rules of 9: Upper limbs41%
Rules of 9: Lower limbs9%
Rules of 9: genital area1%
Burn Depth Classification: Epidermis only Appearance: Erythema, blanches with pressure Sensation: intact, mild to moderate pain Healing: 3-6 days without scarringFirst degree
Burn Depth Classification: Epidermis and superficial dermis, skin appendages intact Appearance: Erythema, blister's moist, elastic, blanches with pressure Sensation: intact, severe pain Healing: 1-3 weeks, scarring unusualSecond degree: superficial
Burn Depth Classification: Epidermis and most dermis, most skin appendages destroyed Appearance: White appearing with erythematous areas dry, waxy, less elastic, reduced blanching to pressure Sensation: Decreased, may be less painful >3 weeks, often with scarring and contracturesSecond degree: Deep
Burn Depth Classification: Epidermis and all of dermis, destruction of all skin appendages Appearance: White, charred, tan, thrombosed vessels, dry and leathery, does not blanch Sensation: Anesthetic, not painful (although surrounding areas of second-degree burns are painful) Healing: Does not heal, sever scarring and contracturesThird-degree
Quick quiz: What electrolyte imbalance occur in Burns? a. Hypocalemia b. Hyperkalemiab. Hyperkalemia
A 60 year old man has been burned in a house fire. He has partial and full thickness burns to the anterior surface of his neck, chest, and abdomen. The approximate percentage of burn injury sustained is?1% anterior surface of his neck 9% anterior surface of his chest 9% and anterior surface of his abdomen total: 19%