NUFT 204 Exam #2- Skin Integrity/Wound Care, Activity/Immobility,
Assessment Techniques, Head/Neck/Neuro Assessment & Respiratory
1.define blanching:: pressure is placed on the skin to determine if
coloration returns
*blanch= become pale under applied pressure
2.3 factors that influence pathogenesis of pressure:: - pressure intensity
(in- creased pressure)
- pressure duration (length of pressure)
- tissue tolerance (nutrition, age, hydration status)
3.3 layers of skin:: - epidermis (top layer)
- dermis (inner layer)
- epidermal junction (separates dermis/epidermis)
4.what does blanchable mean?
non-blanachable?: - skin turns pale when pressure is applied (indicates
tissue perfusion)
- skin remains red when pressure is applied (indicates high risk for
ulcers)
5.how can hydration be tested?
what areas can be tested?: - pinching the skin; if it returns quickly,
hydration is indicated
- hand/clavicle
6. is the mechanical force exerted when skin is dragged across a
coarse surface, such as bed linens: friction
7.define shear:: force exerted parallel to skin
8. is pulling the bones of the pelvis in one direction and the skin in the
opposite direction: shear
9.can shear injury be examined? why?: no; happens beneath the skin
10.stage 1 pressure ulcer:: intact skin with nonblanchable redness
may include changes in skin temperature, tissue consistency, and/or
sensation
11.stage 2 pressure ulcer:: partial-thickness skin loss involving epidermis,
dermis, or both
12.stage 3 pressure ulcer:: full-thickness skin loss with visible fat
(*with or without undermining and tunneling; drainage and infection
common)
13.stage 4 pressure ulcer:: full-thickness tissue loss with exposed bone,
muscle, or tendon
, NUFT 204 Exam #2- Skin Integrity/Wound Care, Activity/Immobility,
Assessment Techniques, Head/Neck/Neuro Assessment & Respiratory
(*there can be tunneling, undermining, eschar, or slough)
14.how could a blister be classified?: stage II
, NUFT 204 Exam #2- Skin Integrity/Wound Care, Activity/Immobility,
Assessment Techniques, Head/Neck/Neuro Assessment & Respiratory
(*stage II: "skin can be peeled off, or the skin can be intact via a blister
with exudates in it")
15.classify the stage:
- loss of subcutaneous tissue
- bones/tendons NOT visible
- can have slough
- can have tunneling: stage III
16.classify the stage:
- full tissue loss
- can see bone/tendon
- slough/eschar present: stage IV
17.red:
yellow:
black:: - cover
- clean
- debride
18.what does the presence of granulation tissue indicate?: healing process
is taking place; there are new cells forming
19. intention requires a granulation tissue matrix to be built to fill
the wound defect: secondary
(* secondary closure requires more time & energy than primary wound
closure, & creates more scar tissue)
20.describe primary intention:: edges are approximated (healing
should take place quickly)
21.describe secondary intention (3):: - wound open, edges NOT
approximated
- takes longer to heal, higher risk for infection
- significant scarring
(*examples: pressure ulcers, burns, severe lacerations)
22.describe tertiary intention:: wound remains open for a long time;
edges are approximated eventually (lengthy healing process)
*REMEMBER, THIS IS DELAYED PRIMARY INTENTION- combination of
healing by primary and secondary intention and is usually instigated by
the wound care specialist to reduce the risk of infection
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