Exam (elaborations)
N450 Wound & Integumentary Disorders (1).
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N450 Wound & Integumentary Disorders (1).
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N450 Wound & Integumentary Disordersname the essential elements of each part of the skin:
1. epidermis
2. dermis (4)
3. subcutaneous tissue (3) - ANS-1. outer layer of the skin
2. hair follicles, sweat glands, nerve endings, blood vessels
3. capillaries, fat, body of nerve
the greater the half life.... - ANS-the longer it takes to excrete
what are the 5 preventative strategies to prevent a wound from developing? - ANS-1. observe
the skin
2. examine all bony prominences
3. check all assistive devices for ulcers
4. review the braden score
5. turn q2hrs in bed and q1hr in chair
what is a primary and secondary lesions - ANS-1. primary - produced from a disease process
(ex. chickenpox)
2. secondary - produced from patient's activities (ex. pressure ulcer, scratching chickenpox)
what is the importance of the line of demarcation? - ANS-it indicates that there isn't enough
circulation AEB the absence of hair growth (nothing is feeding the hair follicles); because
vessels and nerves run in packs, there is potentially diminished sensation in the area
T/F people with diabetic neuropathy who have a foot ulcer can have pain - ANS-T - pain is
described as burning, stabbing or shooting
T/F moist wound therapy is the gold standard for mgmt of most chronic wounds but not for
wounds without adequate vascular supply - ANS-T - moisture promotes epithelial growth if
vascular supply is present; if no vascular supply, it creates a medium for bacteria
name and describe the 3 classifications of wounds - ANS-1. superficial - loss of epidermis
2. partial-thickness - loss of epidermis and dermis
3. full-thickness - loss of dermis, SQ, fat and potentially bone
how are those who are obese at risk for integumentary complications? - ANS-they have
increased weight that presses on their skin onto the sheets; additionally, they have less
movement and more moisture can be trapped
who are the 4 clients at risk of skin breakdown - ANS-1. elderly
, 2. obese
3. immobile
4. confused/dementia
what are the ABCD's for assessment of skin lesions? - ANS-1. asymmetry of shape (more
irregular = more problematic)
2. border irregularity (topography, lips, etc.)
3. color variation (pallor, cyanosis, inflammation, etc.)
4. diameter >5mm
where do you assess dark skinned clients for skin discoloration? - ANS-their mucous
membranes; don't assess their sclera because they could have subconjunctival fat deposits
which could have a misinterpreted yellow hue
what is a pressure ulcer? at the cellular level what happens? - ANS-a localized injury to the skin
and other underlying tissue over a bony prominence; because there is so much pressure, it is
restricting blood flow to the tissues, ultimately resulting in tissue ischemia and then tissue death
via palpation and blanching, how can you tell if deep tissue damage is potentially present? -
ANS-to healthy tissue, if you apply pressure and release, the skin blanches and then the
erythema returns as the vessels vasodilate - this is called blanchable hyperemia (redness); if
you press of the erythematous area and it does not blanch but remains red, damage is probable
(non-blanchable erythema)
Bruising indicates ____ - ANS-deep tissue injury
describe the pressure ulcer stage 1 - ANS-nonblanchable redness - reddened area does not
blanch with pressure; skin is intact; other S/S include edema, warmth, pain
describe the pressure ulcer stage 2 - ANS-partial thickness loss of epidermis and part of dermis
that presents as a shallow/shiny ulcer with red-pink wound bed or an intact or ruptured blistered
describe the pressure ulcer stage 3 - ANS-full-thickness skin loss characterized by potential
tunneling, exudate and loss of subcutaneous tissue; no visible sign of bone, tendon or muscle
describe the pressure ulcer stage 4 - ANS-full-thickness skin loss characterized by tunneling,
exudate, subcutaneous tissue loss, and damage to muscle/bone; black or brown purulent
damage
why is it important to characterize wounds based on their partial or full thickness? - ANS-it
changes the healing process; partial-thickness wounds heal through epithelial regeneration
while full-thickness wounds heal by forming scar tissue (takes longer)
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