Fundamentals Ch. 36 Skin And Wound Care
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Describe factors affecting skin integrity. Identify clients at risk for pressures. Describe the four stages of pressure ulcer development. Differentiate primary and secondary wound healing. Describe the three phases of wound healing. Identify three major types of wound exudate. Identify the main complications of and factors that affect wound healing. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. Identify nursing diagnoses associated with impaired skin integrity. Identify essential aspects of planning care to maintain skin integrity and promote wound healing. Discuss measures to prevent pressure ulcer formation. Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing. Identify p
- 1.
- A.
Clean wounds
- B.
Clean-contaminated wounds
- C.
Contaminated wounds
- D.
Dirty or infected wounds
- 2.
- A.
Primary healing
- B.
Secondary healing
- C.
Tertiary healing
- D.
Quaternary healing
- 3.This exudate is hemorrhagic, has a large number of RBC's, and indicates severe damage to capillaries
- A.
Serous
- B.
Purulent
- C.
Sanguineous
- 4.Which of the following are risk factors for pressure ulcers?
- A.
Decreased mental status
- B.
Fecal and urinary incontinence
- C.
Soft bed
- D.
Excessive body heat
- E.
Cold body
- 5.Full thickness skin loss involving damage or necrosis of subcutaneous tissue
- A.
Stage I
- B.
Stage II
- C.
Stage III
- D.
Stage IV
- 6.Which of the following are ways of preventing pressure ulcers?
- A.
Give supplements to increase caloric intake
- B.
Massage the area
- C.
Decrease humidity
- D.
Frequent toileting
- 7.According to the RYB guide for wound care, what should you do if the wound area is yellow?
- A.
- 8.
- A.
Cold pack
- B.
Compress
- C.
Ice bag
- D.
Cooling sponge bath
- 9.This phase of healing extends from day 3 or 4 until day 21 following injury. Collagen increases in the area, capillaries grow across the wound.
- A.
Inflammatory phase
- B.
Proliferative phase
- C.
Maturation phase
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