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TRANSITIONS
Taylor Chapter 33 - Skin Integrity and Wound Care
| Question | Answer |
|---|---|
| Homeostasis, Inflammation, Proliferation/Repair, and Maturation/Remodeling are the process involved in what? | The processes involved in wound healing. |
| Pressure, desication (dehydration), maceration (overhydration), trauma, edema, infection, excessive bleeding, necrosis (dead tissue), and the presence of biofilm are all factors of what? | Local factors of wound healing. |
| Age, circulation, oxygenation, nutrition, etiology, immunosuppression, pro-inflammatory conditions, overall health status, medications, and compliance to treatment are all factors of what? | Systemic factors of wound healing. |
| Immobile patients, those with poor nutrition and inadequate hydration, altered mental status patients, and older adults are at a greater risk of developing what type of impaired skin integrity? | Pressure Injury |
| Stage 1-Stage 4 and unstageable are the ways of staging what type of wound? | Pressure Injuries |
| Non-blanchable erythema of intact skin is what stage of pressure injury? | Stage 1 |
| Partial-thickness skin loss with exposed dermis is found in what stage of pressure injury? | Stage 2 |
| What stage of pressure injury presents with full-thickness skin loss? | Stage 3 |
| Full-thickness skin and tissue loss occur in what stage of pressure injury? | Stage 4 |
| A pressure injury that presents with obscured full-thickness skin and tissue loss making it impossible to see the wound bed is called what? | Unstageable |
| How are wounds measured and documented? | Length x Width x Depth |
| When measuring for tunneling or undermining of a wound, which direction do you move the cotton-tipped applicator? | Clockwise |
| What is the red tissue within a wound bed? | Granulation Tissue |
| What is the primary color of eschar, or dead tissue? | Black |
| What causes yellow tissue within the wound bed? | Exudate or Slough |
| What color is serous drainage? | Clear |
| What color is sanguineous drainage? | Red |
| What color is serosanguineous drainage? | Pink |
| What color is purulent drainage? | Dark Yellow or Green |
| Which type of drainage often has a foul odor and indicates wound infection? | Purulent |
| What scale is used to predict a client's risk of pressure injury? | Braden Scale |
| What vitamin is important for collagen synthesis and epithelialization? | Vitamin A |
| What is the function of vitamin B complex in wound healing? | Enzymatic Reactions |
| Which vitamin is needed for collagen synthesis, infection resistance, and capillary formation? | Vitamin C |
| Which vitamin is important in prothrombin synthesis? | Vitamin K |
| Which vitamin serves as an activator of enzymes? | Manganese |
| This trio of vitamins assist in collagen synthesis. | Zinc, Copper, and Iron |
| What is the most important way to prevent wound infection? | Proper hand-washing |
| When a client is repositioned and the nurse notes a reddened area on their hip, what is the maximum amount of time it should take for the area to return to normal skin tone? | 2 hours |
Created by:
bwk
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