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Question 1

skin meaning

Answer 1

Skin is a dynamic organ in a constant state of
change; cells of the outer layers continuously shed and are replaced by inner cells
moving to the surface.
the largest organ of the body, making up 16% of body weight

Question 2

skin function

Answer 2

immune function, temperature regulation,

sensation and vitamin production.

Question 3

acute wound example

Answer 3

is the result of tissue damaged by trauma. This may be
deliberate, as in surgical wounds of procedures, or be due to accidents caused by
blunt force, projectiles, heat, electricity, chemicals or friction.

Question 4

CHRONIC wound

Answer 4

fails to progress or respond to treatment over the normal
expected healing time frame (4 weeks) and becomes “stuck” in the inflammatory
phase.Wound chronicity is attributed to the presence of intrinsic and extrinsic
factors including medications, poor nutrition, co-morbidities or inappropriate
dressing selection

Question 5

LAYERS OF SKIN

Answer 5

Epidermis
demis
hypodermis

Question 6

epidermis

Answer 6

Is the outer layer of the skin, comprised of epithelial cells
 Regenerated every 2-4 weeks, subject to an individual’s
age and friction forces applied to the skin
 Receives nutrients from the dermis below
 Comprised of 4 to 5 layers depending on the body location

Question 7

Dermis

Answer 7

 The middle layer of the skin, made up of two layers
 Contains nerves, connective tissue, collagen, elastin and
specialized cells such as fibroblasts and mast cells
 Responsible for inflammatory reactions which occur in
response to trauma and infection
 Has receptors for heat, cold, pain, pressure, itch and
tickle

Question 8

Hypodermis:

Answer 8

 Is the inner most layer of the skin, referred to as the
subcutaneous layer
 Supports the dermis and epidermis
 Comprised of adipose tissue, connective tissue and blood
vessels
 Functions to store lipids, protect underlying organs,
provide insulation and regulate temperature

Question 9

ASSESSMENT

Answer 9

History
The patient’s medical, surgical, pharmacological and
social history
 Examination
Of the patient as a whole; then focus on the wound
 Investigations
What bloods, x-rays, scans do you require to help you
make your…
 Diagnosis
 Implementation
Of the plan of care

Question 10

Inspection/Observation

Answer 10

Look:
Palpate:

Question 11

Inspection/Observation

Look:

Answer 11

Colour of the skin (is it pale/flushed, cyanotic, burned tissue)
 Rash: Note the size, colour, texture and shape of the lesions (e.g.: raised or flat, fluid
filled) and the number and distribution (e.g.: sparse, numerous, over limbs etc.), itchy,
painful.
Note which area of the body it covers.
 Bruising/wounds/pressure injuries: Assess any existing wounds and utilise a Wound Care
Assessment tab in the EMR flowsheet for ongoing wound assessment and management.
 Examine high risk areas regularly, including bony prominences and equipment sites
(masks, plasters, tubes, drains, etc.) for pressure injuries. Report any irregular
bruising.
 Nevi/Moles: Observe for size, any irregular borders, variation in colours. Larger nevi
and changing ones should be reviewed by appropriate medical staff.
 Hair: observe the condition ( especially the scalp) Cradle cap is most common in
newborns and is identified by thick, crusty scales over the scalp. Observe for lice or
ticks

Question 12

Palpate:

Answer 12

 Skin temperature, moisture, turgor, oedema, deformities, haematomas and crepitus
 Hair texture for brittleness, moisture