Wound Healing and Skin Integrity Quiz

Questions and Answers

What happens to the wound when the infection risk is reduced?

The wound will be closed later.

The wound needs to be closed if it was initially left open.

False

The wound is being observed for drainage due to the cause of surgery.

True

Which action made by the nurse demonstrates appropriate wound classification?

Classifying the wound according to the degree of burn. Signup and view all the answers

What stage should the full-thickness wound be documented as when it extends into subcutaneous tissue?

Stage III Signup and view all the answers

What is defined as intact, non-blistered skin?

Stage I Signup and view all the answers

What involves partial-thickness wounds involving the epidermis and dermis?

Stage II Signup and view all the answers

What kind of wounds extend into the subcutaneous tissue?

Stage III Signup and view all the answers

What are full-thickness wounds that involve the exposure of muscle, bone, or connective tissue classified as?

Stage IV Signup and view all the answers

Which statement reflects a misunderstanding about burn wound classification?

I can classify burn wounds according to the depth and width of the lesion. Signup and view all the answers

What phase of wound healing is indicated when new tissue has a granular, bumpy texture?

Proliferative Signup and view all the answers

What is the first phase of wound healing involving bleeding?

The inflammatory phase Signup and view all the answers

What phase involves new tissue that bleeds easily and has a granular texture?

The proliferative phase Signup and view all the answers

What is the final phase of wound healing known for collagen deposition?

The maturation phase Signup and view all the answers

Which response indicates effective learning about diabetes mellitus affecting skin integrity?

Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems. Signup and view all the answers

Which patient is most at risk for developing a pressure ulcer?

Patient with unrelieved pressure exceeding 12-32 mmHg. Signup and view all the answers

What indicates proper assessment of a patient’s incision healing after surgery?

Palpating the area of induration next to the incision line. Signup and view all the answers

What type of opening is described by an enterocutaneous fistula?

Between the skin and the intestines. Signup and view all the answers

What is the term for an opening between the intestines and the vagina?

Enterovaginal fistula Signup and view all the answers

What does 'enterocutaneous' refer to?

An opening between the skin and the intestines. Signup and view all the answers

What does 'entero' mean?

Intestine Signup and view all the answers

What does 'cutaneous' mean?

Skin Signup and view all the answers

Which statement indicates effective teaching about patients at risk for pressure ulcers?

Patients with zinc deficiencies are at risk for pressure ulcers. Signup and view all the answers

What complications arise when intestines protrude through a surgical incision?

Evisceration Signup and view all the answers

What refers to partial or complete separation of tissue layers?

Dehiscence Signup and view all the answers

What is the term for an abnormal connection between two body parts?

Fistula Signup and view all the answers

What do pressure ulcers result from?

Tissue ischemia Signup and view all the answers

What indicates that a patient is at highest risk of developing a pressure ulcer?

75-year-old patient with diabetes who is hospitalized for a hip fracture. Signup and view all the answers

What is the best response regarding smoking's effect on wound healing?

Smoking decreases blood and oxygen circulation. Signup and view all the answers

What characterizes a Stage II pressure ulcer?

Partial-thickness superficial skin loss, abrasion, blister, or shallow crater Signup and view all the answers

What is defined as full-thickness tissue loss in a Stage IV pressure ulcer?

Full-thickness tissue loss with exposed bone, tendon, or muscle Signup and view all the answers

What indicates a suspected deep tissue injury?

An area of purplish, maroon, intact skin or a blood-filled blister Signup and view all the answers

What characteristics differentiate a friction injury from a shear injury?

Involvement of tissue Signup and view all the answers

Which foods should be included for a patient with a zinc deficiency?

Legumes Signup and view all the answers

What role does zinc play in the body?

Wound healing Signup and view all the answers

What does zinc support in relation to tissue?

Collagen formation, host defenses, and protein synthesis Signup and view all the answers

What signifies blanched redness over a bony prominence?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode Signup and view all the answers

What is the first sign of a bed sore?

Redness Signup and view all the answers

What occurs when blood vessels are compressed, and skin returns to red after removing pressure?

Blanching hyperemia Signup and view all the answers

If the area does not blanch when pressure is applied, tissue damage is likely.

True Signup and view all the answers

What dressing is appropriate for a Stage I pressure ulcer?

A transparent or hydrocolloid dressing Signup and view all the answers

What dressings are appropriate for Stage II pressure ulcers?

Composite film, hydrocolloid, and hydrogel dressings Signup and view all the answers

What dressings are appropriate for Stage III pressure ulcers?

Hydrocolloid, hydrogen gel covered with foam, calcium alginate, and gauze dressings Signup and view all the answers

What dressings are appropriate for Stage IV pressure ulcers?

Hydrogel covered with foam, calcium alginate, and gauze dressings Signup and view all the answers

What fruits are rich in vitamin C and help in collagen synthesis?

Citrus fruits Signup and view all the answers

What do zinc-rich foods help in?

Protein synthesis Signup and view all the answers

What do wounds interfere with?

the skin's normal functioning. Signup and view all the answers

What contributes to the development of wounds and delay in wound healing?

Multiple internal and external factors, such as comorbidities and medications. Signup and view all the answers

What is one of the most significant factors that affects the appearance and functioning of the skin?

Aging Signup and view all the answers

Which factors affect skin integrity? Select all that apply.

Excessive dryness Signup and view all the answers

What change is associated with aging of the skin?

Reduced insulation and cushioning, which increases the risk for skin trauma and temperature extremes. Signup and view all the answers

What external forces can result in pressure ulcers? Select all that apply.

Friction Signup and view all the answers

Knowledge of various wound classifications facilitates communication with whom?

patients and health care professionals. Signup and view all the answers

What does classification by skin integrity include?

Open wounds and closed wounds. Signup and view all the answers

Wounds classified by depth include?

Superficial, partial-thickness, and full-thickness (deep) wounds. Signup and view all the answers

Wounds can be classified by level of contamination into what categories?

Clean, clean contaminated, contaminated, infected, and colonized. Signup and view all the answers

Wounds classified according to the healing process are known as?

Primary, secondary, or tertiary intention. Signup and view all the answers

Burns are classified according to depth into what categories?

Superficial (first degree), partial-thickness (second degree), or full-thickness (third degree). Signup and view all the answers

Pressure ulcers are classified based on?

type or stage of ulcer, from stage I to unstageable. Signup and view all the answers

How are wounds classified? Select all that apply.

Depth Signup and view all the answers

Which wound is classified as a closed wound?

Bruise Signup and view all the answers

Which statements are true about superficial or partial-thickness wounds? Select all that apply.

Partial-thickness wounds affect the epidermis and the dermis. Signup and view all the answers

What results in pain and redness?

Superficial Signup and view all the answers

What results in extreme pain and blistering?

superficial and deep partial-thickness. Signup and view all the answers

What results in white or brown areas, charring, and loss of sensation?

Full-Thickness and Deep Full-Thickness. Signup and view all the answers

What indicates Stage I of a pressure ulcer?

Intact, non-blistered skin. Signup and view all the answers

What characterizes Stage II of a pressure ulcer?

Partial-thickness wound, involving the epidermis and dermis. Signup and view all the answers

What characterizes Stage III of a pressure ulcer?

Full-thickness wound, extending into the subcutaneous tissue. Signup and view all the answers

What characterizes an unstageable pressure ulcer?

Full-thickness wound with necrotic tissue (eschar). Signup and view all the answers

How quickly healing occurs can be affected by the presence of existing complicating factors, such as?

disease or wound contamination. Signup and view all the answers

What are the three phases of wound healing?

Inflammatory phase, Proliferative phase, Maturation phase (remodeling). Signup and view all the answers

What occurs during the inflammatory phase of wound healing?

Blood clotting and the natural process of cleaning the wound. Signup and view all the answers

What occurs during the proliferative phase of wound healing?

Repair, filling in the wound bed with new tissue, and resurfacing the wound with skin. Signup and view all the answers

What occurs during the maturation phase of wound healing?

Formation and strengthening of scar tissue. Signup and view all the answers

Factors that affect wound healing are similar to those that affect the?

skin's integrity. Signup and view all the answers

Factors that can affect and ultimately slow or delay wound healing include?

disease, smoking, age, nutrition, and infection. Signup and view all the answers

Complications of wound healing include?

dehiscence, evisceration, and fistulas. Signup and view all the answers

What is a pressure ulcer?

A wound to the skin and/or underlying tissue, usually over a bony prominence, and is the result of pressure. Signup and view all the answers

What roles do nursing play in relation to pressure ulcers?

Identification of patients at risk for pressure ulcers and prevention. Signup and view all the answers

What is dehiscence?

The separation of a surgical incision or rupture of a wound closure. Signup and view all the answers

What is evisceration?

The protrusion of an internal organ through a wound or surgical incision. Signup and view all the answers

What is fistula formation?

Abnormal passageway between two organs or between an internal organ and the body surface. Signup and view all the answers

What is the first phase of wound healing?

Inflammatory Signup and view all the answers

What two primary complications of wound healing can occur when tissues of surgical incisions are under physical stress?

Dehiscence and evisceration Signup and view all the answers

What is a fistula?

Abnormal connection between two internal organs or between protruding internal organ and the outside of the body. Signup and view all the answers

Which factors are related to pressure ulcers? Select all that apply.

Immobility Signup and view all the answers

How does sensory loss relate to the formation of a pressure ulcer?

Patients may be unable to feel pain or discomfort. Signup and view all the answers

Wounds may be classified by?

underlying cause, a description of the skin's integrity, wound depth, degree of contamination, and phase of the healing process. Signup and view all the answers

Burns are usually classified by?

the layers of skin damaged. Signup and view all the answers

Pressure ulcers are classified by?

staging based on exposed tissue layers. Signup and view all the answers

What does the inflammatory phase of wound healing involve?

Blood clotting and wound cleansing. Signup and view all the answers

What occurs during the proliferative phase of wound healing?

Repair of the defect and filling of the wound bed. Signup and view all the answers

What is the maturation phase in wound healing?

Sometimes called remodeling, involves the formation and strengthening of scar tissue. Signup and view all the answers

What variety of factors can negatively impact wound healing?

Disease, nutritional deficits, age, and infection. Signup and view all the answers

What are complications of wound healing?

Dehiscence, evisceration, and fistula formation. Signup and view all the answers

What are pressure ulcers?

Injuries to the skin that result from pressure, commonly preventable. Signup and view all the answers

What are the causative factors of pressure ulcers?

The intensity and duration of the pressure, friction and shear, sensory deprivation and immobility, moisture, and nutrition deficits. Signup and view all the answers

Which statement made by the student nurse indicates a need for further teaching about delayed wound healing?

Wounds should be kept wet and moist to prevent skin tissue from tightening. Signup and view all the answers

What is the most appropriate nursing action for a patient with diabetes in the emergency department?

Checking the patient's feet. Signup and view all the answers

What demonstrates proper knowledge of wound healing and skin integrity when observing an infected wound?

Reviewing the patient's medications. Signup and view all the answers

What classification would be a standard classification comprehensible to other health care workers?

Open knife wound with contamination. Signup and view all the answers

Which statement indicates effective teaching regarding a closed wound?

A closed wound indicates that underlying tissue damage may still exist. Signup and view all the answers

What is tertiary intention in wound healing?

Tertiary intention is the delayed closure of a wound after it has been left open for a time. Signup and view all the answers

Study Notes

Wound Definition and Impact

Wounds disrupt the normal functioning of the skin, presenting challenges for healing.
Various factors like comorbidities and medications play a crucial role in wound development and healing delays.

Aging and Skin Integrity

Aging significantly influences skin appearance and function, leading to reduced insulation and increased risk for injuries like bedsores.
Important factors affecting skin integrity include medications, vascular diseases, dryness, and nutritional deficits.

Pressure Ulcers

Pressure ulcers result from prolonged pressure and can be exacerbated by shearing forces, friction, and moisture.
Key factors influencing pressure ulcer formation include duration, intensity, moisture, and immobility.

Wound Classification

Wounds can be classified by skin integrity (open vs. closed), depth (superficial, partial-thickness, full-thickness), level of contamination (clean, infected), and healing intention (primary, secondary, tertiary).
Burns are specifically classified by depth: superficial (first degree), partial-thickness (second degree), and full-thickness (third degree).

Phases of Wound Healing

Healing involves three phases:
- Inflammatory phase focuses on blood clotting and cleaning the wound.
- Proliferative phase emphasizes tissue repair and new skin formation.
- Maturation phase (remodeling) concerns scar tissue formation and strengthening.

Complications in Wound Healing

Potential complications include dehiscence (wound opening), evisceration (organ protrusion), and fistula formation (abnormal connections).

Assessing Risks and Healing

Individuals with diabetes, impaired sensitivity, or immobility are at increased risk for developing wounds or pressure ulcers.
Medications, especially steroids, can impede the healing process by suppressing cellular response.

Patient Education and Assessment

Education on proper wound care is essential, emphasizing that closed wounds may still harbor underlying injuries.
Regular foot checks in diabetic patients are critical due to their heightened risk for foot wounds.

Incorrect Statements and Misconceptions

Misunderstandings include the belief that wounds should be excessively moist, when in fact, this can complicate healing by increasing infection risk.### Classification of Burn Wounds
Burn wounds are classified based on the depth of the lesion but not by its width or the cause of the burn.
Misunderstandings about burn classification may lead to inappropriate assessments and treatments.

Stages of Wound Healing

Inflammatory Phase
- Initial response to a wound; characterized by bleeding as the body's primary reaction.
Proliferative Phase
- Involves new tissue formation, which appears granular and bumpy, and can bleed easily.
Maturation Phase
- Final phase known as remodeling; collagen deposition continues, and scars form and strengthen over time.

Effects of Diabetes Mellitus on Wound Healing

Diabetes impacts micro-vascular and macro-vascular systems, leading to reduced blood flow and nutrient delivery, negatively affecting skin integrity and healing process.

Risk Factors for Pressure Ulcers

Unrelieved pressure beyond 12-32 mmHg poses the highest risk for pressure ulcers.
Factors such as age, immobility, and certain health conditions like diabetes increase the likelihood of developing pressure ulcers.

Patient Assessment Techniques

Effective assessment of healing incisions includes palpating areas around the incision for induration, indicating collagen formation.
An absence of a "healing ridge" suggests increased risk of dehiscence or evisceration.

Types of Fistulas

Enterocutaneous Fistula
- An opening between the skin and the intestines.
Enterovaginal Fistula
- An opening between the intestines and the vagina.

Nutritional Considerations in Wound Healing

Zinc deficiencies can adversely affect wound healing; foods rich in zinc include meat and legumes.
Nutritional status impacts skin integrity and recovery from wounds.

Complications in Wound Healing

Evisceration
- Total separation of tissue layers with visceral organs protruding; requires immediate medical attention.
Dehiscence
- Partial or complete separation of tissue layers without organ protrusion.

Pressure Ulcer Staging

Stage II Pressure Ulcer
- Partial-thickness skin loss, indicated by superficial abrasions, blisters, or shallow crater.
Stage III Pressure Ulcer
- Full-thickness tissue loss; subcutaneous fat may be visible.
Stage IV Pressure Ulcer
- Full-thickness tissue loss with exposed bone, tendon, or muscle; may involve undermining and tunneling.

Symptoms and Indicators

Redness is often the first sign of a developing pressure ulcer.
Pressure that leads to blanching hyperemia indicates the body's effort to recover from ischemia.

Role of Vitamins and Minerals in Healing

Citrus fruits, high in vitamin C, are beneficial for collagen synthesis and overall wound healing.
Zinc’s role in protein synthesis is crucial for effective wound recovery.

Dressing Recommendations for Pressure Ulcers

Stage I ulcers can be treated with transparent or hydrocolloid dressings.
Stage II recommended dressings include composite film, hydrocolloid, and hydrogel.
Stage III may require hydrocolloid, alginate, or gauze dressings.
Stage IV ulcers may necessitate hydrogel, alginate, and gauze dressings.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

Test your knowledge on factors affecting wound healing and skin integrity. This quiz covers various aspects, including the impact of aging and other contributing factors. Assess your understanding of how wounds can interfere with skin function.