Nursing Fundamentals: Skin Integrity & Wound Care

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Questions and Answers

What is the term for normal skin with no interruptions by wounds?

Intact skin (correct)

Skin integrity

Skin health

Wound healing

What is the primary function of the skin in maintaining health?

Aiding in digestion

Producing hormones

Regulating body temperature

Protecting the individual from injury (correct)

What is a factor that can influence skin integrity?

Genetic factors only

Both internal and external factors (correct)

Environmental factors only

Nutritional factors only

What type of wound is characterized by minimal inflammation and no entry into the respiratory, gastrointestinal, genital, or urinary tracts?

Clean wound Signup and view all the answers

What happens to the skin or mucous membrane surface in an open wound?

It is broken Signup and view all the answers

What is an example of an intentional wound?

Self-inflicted wound Signup and view all the answers

What is the primary goal of nursing functions in maintaining skin integrity?

Maintaining skin integrity and promoting wound healing Signup and view all the answers

What type of wound is characterized by evidence of inflammation?

Contaminated wound Signup and view all the answers

What type of wound is caused by a blow from a blunt instrument?

Contusion Signup and view all the answers

What type of wound is characterized by the presence of dead tissue?

Dirty or infected wound Signup and view all the answers

What is the term for a surface scrape, either unintentional or intentional?

Abrasion Signup and view all the answers

What type of wound is caused by a sharp instrument, either intentional or unintentional?

Puncture Signup and view all the answers

What type of wound involves the tearing of tissues, often from accidents?

Laceration Signup and view all the answers

What is the term for a wound made by a sharp instrument, such as a knife or scalpel?

Incision Signup and view all the answers

What is the primary reason for maintaining skin integrity in nursing?

To protect the individual from injury Signup and view all the answers

What is a characteristic of clean-contaminated wounds?

Entry into respiratory, gastrointestinal, genital, or urinary tract Signup and view all the answers

What is the difference between open and closed wounds?

Open wounds have a break in the skin, while closed wounds do not Signup and view all the answers

What is the primary goal of nursing functions in relation to wound care?

To promote wound healing Signup and view all the answers

What is the relationship between skin integrity and internal factors?

Internal factors, such as genetic makeup, can influence skin integrity Signup and view all the answers

Which type of wound is characterized by the presence of purulent drainage?

Dirty wound Signup and view all the answers

What type of wound is caused by a sharp instrument, either intentional or unintentional, and involves penetration of the skin and underlying tissues?

Puncture Signup and view all the answers

Which type of wound shows evidence of inflammation?

Contaminated wound Signup and view all the answers

What type of wound involves the tearing of tissues, often from machinery accidents?

Laceration Signup and view all the answers

Which type of wound is characterized by dead tissue?

Dirty wound Signup and view all the answers

Study Notes

Skin Integrity

Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds.
The appearance of the skin and skin integrity are influenced by internal factors (genetic, age, and underlying health) and external factors (activity).

Factors Affecting Skin Integrity

Age
Genetic factors
Underlying health
External factors (activity)

Wound Classification

Wounds can be classified as intentional or unintentional.
Closed wounds: tissues are traumatized without a break in the skin.
Open wounds: skin or mucous membrane surface is broken.

Wound Contamination

Clean wounds: uninfected wounds with minimal inflammation and no entry into respiratory, gastrointestinal, genital, or urinary tracts.
Clean-contaminated wounds: surgical wounds with entry into respiratory, gastrointestinal, genital, or urinary tract, but no evidence of infection.
Contaminated wounds: open, fresh, accidental wounds and surgical wounds showing evidence of inflammation.
Dirty or infected wounds: wounds containing dead tissue and wounds with evidence of a clinical infection.

Specific Types of Wounds

Incision: wound caused by a sharp instrument (e.g., knife or scalpel).
Contusion: wound caused by a blow from a blunt instrument.
Abrasion: surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks).
Puncture: penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional.
Laceration: tissues torn apart, often from accidents (e.g., with machinery).
Penetrating wound: penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments).

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Description

This quiz assesses your understanding of skin integrity and wound care, including factors that affect skin integrity and different types of wounds. Covers the importance of nursing functions in maintaining skin health.