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NUFT 204 Exam 2 (Latest -
1. define blanching:
Answer: 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:
Answer:
- pressure intensity (in- creased pressure)
- pressure duration (length of pressure)
- tissue tolerance (nutrition, age, hydration status)
3. 3 layers of skin:
Answer:
- epidermis (top layer)
- dermis (inner layer)
- epidermal junction (separates dermis/epidermis)
- what does blanchable mean?
non-blanachable?
Answer:
- skin turns pale when pressure is applied (indicates tissue perfusion)
- skin remains red when pressure is applied (indicates high risk for ulcers)
- how can hydration be tested?
what areas can be tested?
Answer:
- pinching the skin; if it returns quickly, hydration is indicated
- hand/clavicle
- is the mechanical force exerted when skin is dragged across a coarse surface, such as
bed linens
Answer: friction
7. define shear:
Answer: force exerted parallel to skin
- is pulling the bones of the pelvis in one direction and the skin in the opposite
direction 1 / 3
Answer: shear
- can shear injury be examined? why?
Answer: no; happens beneath the skin
10. stage 1 pressure ulcer:
Answer: intact skin with nonblanchable redness
may include changes in skin temperature, tissue consistency, and/or sensation
11. stage 2 pressure ulcer:
Answer: partial-thickness skin loss involving epidermis, dermis, or both
12. stage 3 pressure ulcer:
Answer: full-thickness skin loss with visible fat
(*with or without undermining and tunneling; drainage and infection common)
13. stage 4 pressure ulcer:
Answer: full-thickness tissue loss with exposed bone, muscle, or tendon
(*there can be tunneling, undermining, eschar, or slough)
- how could a blister be classified?
Answer: stage II
(*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
Answer: stage III
16. classify the stage:
- full tissue loss
- can see bone/tendon
- slough/eschar present
Answer: stage IV 2 / 3
17. red:
yellow:
black:
Answer:
- cover
- clean
- debride
- what does the presence of granulation tissue indicate?
Answer: healing process is taking place; there are new cells forming
- intention requires a granulation tissue matrix to be built to fill the wound defect
Answer: secondary
(* secondary closure requires more time & energy than primary wound closure, & creates more scar tissue)
20. describe primary intention:
Answer: edges are approximated (healing should take place quickly)
21. describe secondary intention (3):
Answer:
- 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:
Answer: 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
23. define wound dehiscence:
Answer: surgical complication in which wound ruptures along incision
(layers of skin and tissue separate)
- / 3
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