Chapter 34 - Skin Integrity & Wound Healing (Week 4 Quiz) Flashcards
The layers of the skin are:
- ______ - the outer portion of the skin (4-5 layers). It is covered by the ______ _______ which is composed of numerous thicknesses of dead cells; it functions as a barrier, restricts water loss, prevents fluid, pathogens and chemicals form entering. The innermost layer is the ______ _______, which continually produces new cells, pushing the older cells toward the skin surface.
- _______ - lies below #1 and above the subcutaneous tissue. It provides strength and elasticity to the skin and is generously supplied with blood vessels.
- The _______ _______ is composed of connective and adipose tissues. It provides insulation, protection and a reserve of calories .
1)
Epidermis
Stratum corneum (corn–>corn husk–> outermost part of corn)
Stratum germinativum (germanate = produce new life)
2)
Dermis
3)
Subcutaneous layer
Deeper in the epidermis are ________, which produce _____, a pigment that gives skin its color and provides protection from UV.
melanocytes; melanin
Age-related factors that affect skin:
Age —
older adult skin:
-oil and sebaceous glands less active,
-Reduced collagen leads to loss of elasticity; prone to injury
-drier - XEROSIS = itchy red dry cracked skin making them more prone to injury -
-areas of hyperpigmentation,
-Due to impaired mobility: Not changing positions causes ulcers, reposition every 2 hours.
Mobility status — increased pressure, shearing, and friction can lead to breakdown
infants have thin skin that is more permeable which is why they are susceptible to diaper rash.
Puberty leads to increased sebaceous and sweat gland activity (acne and body odor is the result).
Skin condition reflects nutritional status. Adquate intake of _______, _______, ______, _____ and _____ are essential to maintaining skin integrity.
PCCCH
Protein: essential to maintain skin, repair minor defects & preserve intravascular volume
Cholesterol: abnormal low levels predispose patients to skin breakdown & inhibit wound healing; these fats provide fuel for wound healing and maintain waterproof barrier.
calorie intake: If you do not eat enough, of the needed nutrients, your body will use what you do eat as energy instead of for healing your skin. PROLONGED lack of calories = weight loss, loss of subcutaneous tissue & muscle atrophy
ascorbic acid (vitamin C): Involved in formation & maintenance of collagen Deficiency= delays wound healing
Hydration-poor turgor if dehydrated
p.833
PCCCH - protein, cholesterol,calories, c vitamins, and hydration
Pts with diminished tactile senses are more prone to skin breakdown. Why?
- Unable to feel pressure in affected area; may not shift position to relieve pressure over bony prominences.
- May not notice cut or wound on area with reduced sensation, leading to late treatment and more chance for infection.
______ _______ interferes with tissue metabolism and is the main cause of chronic wounds.
Impaired _______ circulation restricts activity, produces pain, leads to muscle atrophy & development of thin tissue, prone to ischemia & necrosis. Ischemia means inadequate blood brought TO tissues.
Impaired ______ circulation results in engorged tissue with high levels of metabolic waste products that are prone to edema, ulceration & skin breakdown.
Impaired circulation:
impaired arterial circulation (to body from heart)
impaired venous circulation (blood sends waste to various organs for removal)
Both forms of impairment delay wound healing and is one of the main causes of chronic wounds.
(always remember you need the blood to flow to the area/less flow=less healing)
T or F: Side effects & idiosyncratic reactions to medication can affect skin integrity & delay wound healing. Any medication that causes: Itching(pruritus), Rashes(dermatoses), Photosensitivity, Alopecia, Pigmentation changes,; can result in changes that impair skin integrity or delay healing
True
p.833
Exposure to moisture leads to _________ (softening of the skin) and increases likelihood of breakdown; incontinence (bowl and urine) & Fever are most common causes of it.
Maceration
Bowel incontinence can lead to ________ because feces contains digestive enzymes that can destroy superficial skin layers. This can lead to _ _ _ _ , dermatitits, pressure ulcers and infection.
excoriation
MASD=moisture associated skin damage
How do fevers cause skin breakdown?
- Leads to sweating which causes maceration.
2. Increases metabolic rate which raises tissue demand for oxygen.
________ of a wound refers to the presence of microorganism in the wound.
Contamination.
All chronic wound are considered contaminated.
As bacteria begin to increase in numbers, a wound is said to be _____, though microbes are not causing harm.
When the bacteria beging to overwhelm the body’s defenses, the wound is then referred to as ______ colonized.
colonized
critically colonized
An ______ implies the microorganisms are causing harm by releasing toxins, invading body tissue & increasing the metabolic demand of tissue. This increases vulnerability to skin breakdown & impedes healing of open wounds
infection
What are lifestyle habits that affect skin integrity?
- Tanning - exposes to UV leading to melanoma
- Bathing - overbathing rids of normal flora/dries skin; underbathing leads to bacteria build up which can infect wound
- Piercings & Tattoos - risk for scarring and infection; piercings prone to: infections, sepsis, endocardititis, hepatitis, TSS.
- Smoking - compromises O2 supply; prone to breakdown; interferes with vitamin C absorption
Of the following factors, which would put a client at greatest risk for impaired skin integrity?
a. the medication digoxin b. moisture c. decreased sensation d. dehydration
Correct answer: C
Decreased sensation would greatly increase the risk for injury with a tear or break in the skin. This could lead to a delay in seeking treatment due to lack of awareness.
T or F: Wounds are classified solely according to length of time the wound has existed.
False.
Wounds are classified according to length of time the wound has existed, as well as the condition of the wound (contamination, severity, etc.)
This video is graphic. Contains images of various wounds and their labels:
https://www.youtube.com/watch?v=8pBpYQkCdvY
We can classify by skin integrity of the wound. No breaks in the skin is describe as ______.
If there is a break in the skin or mucous membranes, it is considered ____.
Closed
Open (Examples: abrasion, abscess, contusion, crushing, incision, laceration, penetrating, puncture, and tunnel) Table 34-1 on page 835
If a wound is expected to be of short duration is referred to as _____.
acute
These wounds heal spontaneously without complications through the three phases of wound healing (inflammation, proliferation, and maturation).
Wounds that exceed the expected length of recovery are classified as _____.
chronic.
The natural healing process is interrupted due to infection, continued trauma, ischemia, or edema.
Examples of Chronic Wounds:
pressure (decubitous), arterial, venous and diabetic ulcers.
_____ wounds are uninfected wounds such as surgical wounds, with minimal inflammation
_____ ________ wounds are also surgical but have incisions that enter the GI, Resp and genitourinary tracts.
clean
Clean - contaminated
______ wounds include open, traumatic wounds or surgical incisions in which MAJOR BREAK in asepsis occurs. The risk of infection for these is high.
contaminated
Wounds are considered _______ when bacteria counts in the tissue are above 100,000 organisms per gram of tissue. Signs of this include: redness, swelling, fever, foul odor, severe or increasing pain, large amount of drainage, or warmth of surrounding tissue.
infection
An example of a ________ wound is a scrape on your knee. Caused by friction, shearing, or burning.
_______ ______ wounds extend through the epidermis but not down to the dermis.
The ______ descriptor is sometimes added to indicate that the wound involves internal organs (examples: gunshot wound; causes pneumo/hemothorax)
Superficial
Partial thickness (think of it being partially as thick as the epidermis and dermis combined. Full thickness wounds are the full thickness of epi/dermis and subcutaneous tissues).
penetrating
Types of wound healing:
- ______ is when a wound affects only the epidermal and dermis; No scar forms.
- _____ _____ involves Minimal scarring=minimal or no tissue loss. Edges of wound are either clean surgical incision or approximated (try to align the skin before sew/staple/strips). Little scarring is expected (possibly a tiny hairline scar)
- Healing by ______ ______
occurs when a wound involves either: 1) extensive tissue loss that prevents edges from approximating (they don’t come together); or 2)should not be closed due to infection (Wound left open =Heals from inner layer to surface. Fills in with beefy red granulation tissue) - _____ ______ , also called delayed primary closure, occurs when two surfaces of granulation tissues are brought together. It is closed with sutures after being allowed to heal with secondary intention. Requires strict aseptic technique during dressing changes because they are prone to infection.
page 837 has visual aid for healing processes
- Regeneration/Epithelial (partial thickness wounds heal this way).
- Primary intention (clean surgical incision heals this way)
- Secondary intention (pressure ulcers and infected wounds are in this category). (2nd, two, two sides don’t match up)
- Tertiary intention (clean contaminated or contaminated wounds)
Very important video to watch in conjunction with the next few cards.
https://www.youtube.com/watch?v=6qU-0ETo5_s
skip to 37 seconds.
Note: our book combines maturation phase and remodeling phase together… but the visual is perfect!
Wound healing occurs in three stages…what are they?
- inflammatory- the cleansing phase (days 1 to 5)
- proliferative (aka regeneration) - occurs from day 5 to 21
- maturation (remodeling) - final phase (from second or third week through up to 6 months)
During the inflammatory phase (1st phase) What takes place?
1 to 5 days
hemostasis - tissues.capillaries are damaged causing blood and plasma to leak into the wound. platelets aggregate and clump. clots are activated and formed.
inflammation - characterized by swelling (edema), redness, pain, and heat. WBCs rush to area to complete phagocytosis of microbes (they eat em up like pacman). Scabs form using plasma proteins and fibrin.
What happens during the proliferative phase (2nd phase)?
5 to 21 days
fibroblasts (that form collagen) and endothelial cells form granulation tissue (which is easily damaged). As the clot or scab is dissolved epithelialization occurs (epithelial cells seal over wound)
What happens during the final stage of healing called Maturation Phase (or remodeling)?
2 weeks to 6 months
The tissues that were laid in the wound bed during the proliferative phase are broken down and remodeled into organized structures (scar tissue), increasing the strength of the tissue
Identify the type of wound healing (primary, secondary, or tertiary intention):
● A wound that heals from inner layer to the surface
● A wound with approximated edges
● A wound that heals by approximating two surfaces of granulation tissue
● A wound that is sutured and has minimal or no tissue loss
Answer:
Secondary intention
Answer:
Primary and tertiary intention
Answer:
Tertiary intention
Answer:
Primary intention
Wounds that heal by primary and tertiary (those with approximated edges) are closed in a number of ways…List some!
(Relates to slide: Nursing Interventions Related to Wound Care (Cont’d))
- adhesive strips (close superficial and closed subq wounds; left on until the separate themselves from the skin).
- sutures - “stitches” absorbent sutures that dissolve are used for organ closure or to connect tissue (anastamose). If put in skin, non absorbent and usually need removal.
staples - low risk of infection than stitches. Difficult to align.
surgical glue - used i low tension, clean wounds.
negative pressure closure - uses secondary and tertiary intention. Vacuum created, pressure reduces edema from swollen tissues/promotes granulation.
Really cool animation on how it works here:
https://www.youtube.com/watch?v=-wxyKEStuDQ
compression -
Drainage is the flow of fluids from a wound or cavity, and often referred to as ______, oozes as a result of inflammation.
exudate
Straw-colored exudate that drains from cleans wounds. Consists of serum that separates our of blood when clot is formed.
Serous exudate
_________ exudate is often seen with deep wounds or wounds in highly vascular areas. It is blood drainage. Fresh=bright red drainage. Old= dark red brown
Sanguineous exudate
________ drainage is a mix of bloody and straw-colored fluid
Serosanguineous
______ exudate contains pus (which is WBCs, bacteria, and cellular debris). It is commonly caused by pyogenic bacteria.
Purulent Exudate (Pu as in PUs)
Red tinged pus that indicate small vessels in the wound have ruptured.
purosanguineous
T or F: common complication of wound healing are hemorrhage, infection, dehiscence, evisceration and fistulas.
True
Sometimes hemostasis is delayed, when a large vessel is injured/clotting disorder exists/pt on anticoagulation therapy. The patient could be bleeding internally or externally.
Signs of internal bleeding are? External bleeding?
Called hemorrhage- a complication of wound healing….
Internal-swelling of affected part, pain, change in vitals (dec BP/elevated pulse).
External - you will see bloody drainage on dressings/in devices.Remember to look under the pt because blood will pool there.
Rupture (separation) of one or more layers of a wound. NOTHING YOU CAN DO.
Occurs in inflammatory phase of healing before large amount of collagen have strengthened it.
Dehiscence (dehis - detach - detached edges)
associated with abdominal wounds. POP open.
Caused by poor nutrition, inadequate closure of muscles or wound infection. Obese pt at higher risk.
What do you do if your pt encounters dehiscence?
Put something clean over it and call the doctor. Maintain bedrest with 20 degree head elevated and knees flexed.
associated with abdominal wounds.
______ is total separation of
layers of wound in which internal viscera protrude
through the incision. It is rare.
Evisceration
viscera escape = evisceration.
Google the image… you will never forget
:(
What do you do if your pt encounters Evisceration?
Cover wound with sterile towels or dressing soaked in sterile saline solution to prevent form drying out/becoming contaminated. Knees bent.Ready for surgical procedure.
A _____ is an abnormal passage connecting two body cavities.
Fig 34-6
Fistula
How does a fistula form?
An abscess forms which breaks down surrounding tissue and creates the abnormal passafeway.
The client calls the nurse to the room and states, “Look, my incision is popping open where they did my hip surgery!” The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse’s best action is to
a. Notify the surgeon STAT.
b. Place a clean, sterile 4 x 4 over the incision and monitor the drainage. c. Wrap an ace bandage firmly around the area and have the client maintain bedrest. d. Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon.
B
A 1 cm separation of wound edges only in the center of a surgical incision on the hip is too small to truly be termed dehiscence. Even if there were a large separation, there are no “internal viscera” to protrude.
How to break apart this questions:
- Pt safety - infection control first
- color of fluid - straw colored = serous exudate which means it is a clean wound and clot was formed. Color of dehiscence is serosanguineous.
- the part exposed does not include an internal viscera so it is not evisceration.
______ _______ are localized areas of injury to the skin, and possibly underlying tissue, usually over bony prominence.
Pressure ulcers (aka decubitus ulcers/bedsores)
They are caused by unrelieved pressure that compromise blood flow to an area resulting in ischemia which leads to tissue anoxia and cell death.
T or F: Pressure ulcers can occur in as little times as 2 hours.
True.