Skin Integrity & Wound Care. Ch 32

Question 0

Dermis

Answer 0

Second layer, Elastic connective tissue, contains nerves, hair follicles, glands, blood vessels

Question 1

Epidermis

Answer 1

Top outermost layer, regenerates quickly

Question 2

Subcutaneous tissue

Answer 2

The underlying layer that anchors the skin layers to the underlying tissues of the body

Question 3

Functions of the skin

Answer 3

1. Protection
2. Temp regulation
3. Psychosocial. Pg 919
4. Sensation
5. Vit D production
6. Immunological
7. Absorption. (Increase use in medicinal patches)
8. Elimination

Question 4

Age related skin changes

Answer 4

• Skin becomes thin, easily injured, less insulating, sensation of pain and pressure is reduced
• decrease in sweat gland activity, skin becomes dryer, pruritis (itching)
• healing time is delayed
• amount of melanocytes decline, hair becomes gray-white, uneven skin pigmentation
• collagen fiber is less organized, skin loses elasticity.
• infants skin is easily injures,d subject to infection

Question 5

Wound

Answer 5

Break or disruption in the normal integrity of the skin and tissue

Question 6

Wound classification

Answer 6

Intentional and unintentional
Open and closed
Acute and chronic
Partial thickness,full, complex

Examples pg 923

Question 7

Phases of wound healing

Answer 7

1. Hemostasis- occurs immediately, vessels constrict and clotting begins, exudate causes swelling, incr perfusion creates heat, platelets stimulate migration of cells to next phase
2. Inflammatory- lasts 4-6 days, WBCs/macrophages move to wound, ingest debris, release growth factors for healing
3. Proliferation- w/in 2-3 days, last up to 2-3 wks, regenerative phase, new tissue is built, capillaries grows cross wound, thin layer epi cells and granulation tissue forms.
4. Maturation-final stage, begins about 3 wks-6 mos after injury, collagen is remodeled to make skin stronger, new collagen tissue deposited, scar becomes thin, flat, white

Question 8

Exudate

Answer 8

Plasma and blood components to leak out into the area that is injured forming a liquid
(Homeostasis)

Question 9

Granulation tissue

Answer 9

Foundation for scar tissue development. Made of thin layer epithelial cells formed across the wound reinstating blood flow

Question 10

Desiccation

Answer 10

Dehydration

Question 11

Maceration

Answer 11

Over hydration

Tissue had been soaked in water/fluid

Question 12

Necrosis

Answer 12

Death of tissue

Question 13

Two Factors affecting wound healing

Answer 13

Local and Systemic

Question 14

Local Factors affecting wound healing

Answer 14

Pressure- interferes with blood flow, delays healing
Desiccation- cells dehydrate forming crust cover
Maceration- over hydration
Desiccation-
Trauma-
Edema- interferes with blood supply to the area,
inadequate supply of oxygen and nutrients
Infection-toxins produced by bacterial death
interfere with healing and cause cell death
Necrosis- dead tissue; must be removed for
healing to occur

Question 15

Systemic factors affecting wound healing

Answer 15

1. Age- older adults are more likely to have one or more chronic illnesses impeding healing. Infants and young children at risk due to loose skin binding.
2. Circulation and oxygen- (smoking) adequate blood flow delivers nutrients and oxygen to remove local toxins, bacteria, and other debris.
3. Nutritional status-body requires adequate proteins, carbs, fats, vitamins, minerals
4. Wound Condition- size, presence of infection, foreign bodies.
5. Medications- corticosteroids decrease the inflammatory process, radiation depresses bone marrow function, chronic illnesses, chemotherapy, prolonged antibiotics
6. Immunosupression-diseases (aids,lupus), medication (chemo), age
7. Health status - diabetes

Question 16

Wound complications

Answer 16

Infection, hemorrhage, dehiscence and evisceration, fistula formation

Question 17

Dehiscence

Answer 17

Partial or total separation of wound layers as a result do excessive stress on wounds that are not healed.

Picture of open surgical wound sutures have come apart

Question 18

Evisceration

Answer 18

The wound completely separates with the protrusion of the viscera through the incisional area.
(Picture of intestine coming through incision)

Question 19

Fistula

Answer 19

An abnormal passage from an internal organ to the outside of the body or from one internal organ to another

Question 20

Pressure ulcer

Answer 20

Wound with localized area of tissue necrosis. Acute or chronic

Most occur in older adults as a result of aging, chronic illnesses, immobility, malnutrition, fecal and urinary incontinence, and/or altered consciousness

Question 21

Factors in pressure ulcer development

Answer 21

External Pressure- ischemia, hypoxia, edema,
inflammation, then necrosis and ulcer formation
Friction and Shear- two surfaces rub against each
other. Skin breakdown, wear and tear of tissue
layers.

Question 22

Ischemia

Answer 22

Deficiency of blood in a particular area

Question 23

Difference between friction and shear

Answer 23

Friction- looks like an abrasion, superficial blood vessels damaged

Shear- one layer of tissue slides over another layer. Separates the skin from underlying tissue. Vessels can tear decreasing circulation

Question 24

Risks for pressure ulcer development

Answer 24

Immobility, nutrition and hydration, moisture, mental status, age

Question 25

Pressure ulcer stages

Answer 25

Suspected: purple or maroon localized area. Stage 1: intact skin, nonblanchable redness, usually over bony prominence Stage2: partial thickness loss of dermis, presents as shallow open ulcer Stage 3: full thickness tissue loss, undermining Stage 4: full thickness tissue loss with exposed bone, tendon, muscle

Question 26

Eschar

Answer 26

Thick, leathery scab or dry crust that is necrotic and must be removed before stage can be determined. **eschar in the heels serves as body's natural cover and should not be removed

Question 27

Risk assessment scales

Answer 27

Norton Scale | Braden Scale

Question 28

Debridement

Answer 28

Removal of devitalized tissue and foreign material

Question 29

Additional techniques to promote wound healing

Answer 29

Fibrin sealants, negative pressure wound therapy, growth factors, oxygen therapy, heat and cold therapy, other treatment options for pressure ulcers-> surgery

Question 30

Intentional wound

Answer 30

Result of planned invasive therapy or treatment, purposely created for therapeutic purposes, Edges are clean, bleeding usually controlled, risk for infection is decreased, healing is facilitated

Question 31

Unintentional wounds

Answer 31

Accidental, occur from unexpected trauma, contamination is likely, wound edges are jagged, multiple traumas are common, high risk for infection, longer healing time

Question 32

Open wound

Answer 32

Skin surface is broken, provides portal of entry for microorganisms

Question 33

Closed wound

Answer 33

Results from blow, force or strain caused by trauma, skin surface is not broken, soft tissue is damaged

Question 34

Factors affecting skin

Answer 34

- Unbroken healthy skin defend against invaders - Resistance injury affected by age, illness, underlying tissue - adequately nourished cells resistant to injury - adequate circulation necessary to maintain cell life

Question 35

Causes if skin alteration

Answer 35

- very thin and obese people more susceptible - jaundice - diseases of the skin

Question 36

Principles of wound healing

Answer 36

- Intact skin first line of defense - Surgical asepsis used for acting for the wound - Body responds systematically to trauma - Adequate blood supply is important for normal injury response - Wound healing is promoted when wound is free of foreign material - extent of damage to a persons state of health - response is improved with proper nutrition, protein