Skin

Question 1

functions skin

Answer 1

regulation of heat - blood vessel constrict/dilate
sensation
production vitamin d - sun
regulation toxins and fluid levels - sweat (wastes ammonia and urea)
protection
composition of self image

Question 2

layers skin

Answer 2

epidermis
- no blood supply, renew q 4-6 weeks, outmost layer dead
dermis

• thicker than epidermis, prov strength and elasticity from elastin and collagen (helps with healing), contains vessels

subcutaneous (hypodermis)
- fat tissue, varies weight sex age, cushion internal organs, dermis to muscle and bone

Question 3

structures within skin

Answer 3

melanin - protect UV rays, give skin color
melanocyte - makes melanin
sebaceous gland - lubricates hair and skin
arrector pili muscle - hair erect, goose bumps
free nerve ending - stim sense pain
basal cells - join dermis and epidermis, single layer active cells, produces new cells constantly push way to surface
keratinocytes

Question 4

perfusion

Answer 4

Positive Effects

Adequate perfusion allows oxygen and nutrients to nourish the skin, promoting a healthy protective skin barrier.

Negative Effects

Poor or inadequate perfusion decreases the supply of oxygen and nutrients to the skin, causing it to deteriorate, producing a weak barrier. A prolonged decrease in oxygen to the skin produces the following results:

Decreased collagen formation
Reduced production of cells that make collagen (fibroblasts)
Decreased number of white blood cells (leukocytes)
Reduced migration of cells that help the skin regenerate
Vascular diseases, like peripheral vascular disease and heart failure, can also produce these effects.

Question 5

moisture/hydration

Answer 5

Positive Effects

Adequate moisture allows the skin to stay hydrated and intact.

Negative Effects

Too much moisture for extended periods of time causes the skin to erode from the process of maceration (softening due to excess moisture). The moisture can be stool, urine, drainage from wounds, saliva, mucus, or sweat. Excess moisture can allow bacteria to multiply and break down skin, leading to an increased risk for infection.

A lack of moisture leads to cracking of the skin, leading to skin breakdown and increased risk for infection.

Question 6

nutrition

Answer 6

Positive Effects

Adequate intake of protein, carbohydrates, fats, vitamins, and minerals allows the skin to repair itself quickly. An appropriate number of calories is also necessary to maintain healthy skin.

Negative Effects

Several deficiencies weaken the skin, specifically lack of sufficient calories, protein, vitamin C, vitamin A, zinc, and copper. A lack of calories is especially harmful because damage to the skin requires additional calories to heal; vitamin A, zinc, and copper are needed for healing, too. Protein is especially significant because fibroblasts need protein to make collagen. Vitamin C is necessary for collagen formation, too. Malnutrition that causes an unintentional weight loss of 5% or more and a low body mass index (BMI) can adversely affect skin and healing.

Question 7

medications

Answer 7

Positive Effects

Antibiotics allow the body to fight invading pathogens, thus preventing or eliminating infection.

Negative Effects

Steroids interrupt the inflammatory process (are antiinflammatory), making patients prone to infections and slow healing.

Some antibiotics, antidepressants, and antipsychotics cause photosensitivity, which makes the skin more sensitive to sunlight, resulting in redness/sunburn, rash/hives, and/or itchiness.

Question 8

negative skin effects

Answer 8

shearing/friction
prolonged pressure
diabetes
smoking
UV rays

Question 9

friction/shearing

Answer 9

Friction: Rubs the skin against something, like a bed or medical device, and damages the top layer of the skin

Shear: Combines effects of gravity with friction, like when the sitting patient “slides” down in bed, and causes opposing forces (skin “sticks” to bed but gravity and the patient’s weight pull the patient down), leading to blood vessels being stretched and compressed, reducing blood supply to the area

Question 10

prolonged pressure

Answer 10

Leads to capillaries collapsing → ischemia → skin damage → subcutaneous tissue and muscle damage → tissue death (if pressure is relieved at the beginning of ischemia, damage usually does not occur)
Produces damage if the pressure level is low for an extended period and if the pressure is high for a short period
Produces damage to bony prominences and certain pressure areas based on position
Produces damage if the skin is re-exposed to the same, or even less, pressure

Question 11

diabetes

Answer 11

Affects large blood vessels (macrovascular)
Affects small blood vessels (microvascular)
Alters the acidic pH of the skin, making it less effective at fighting microorganisms
Thickens vessel walls and obstructs blood flow, leading to reduced oxygen and nutrients to the cells
Decreases collagen synthesis and strength
Impairs the immune system: produces weak leukocytes and macrophages

Question 12

smoking

Answer 12

Decreases hemoglobin’s capability to transport oxygen
Causes vessels to constrict and increases clotting ability of the blood due to nicotine, leading to decreased oxygen to cells
Causes wrinkles around mouth

Question 13

UV lights

Answer 13

Includes two major types: ultraviolet light A (UVA) and ultraviolet light B (UVB)
UVB penetrates only the epidermis
UVA penetrates more deeply, into the dermis
Induces degenerative changes in skin cells
Alters skin DNA, increasing risk for skin cancer

Question 14

effects aging

Answer 14

atatched

Question 15

Which statement about ultraviolet light is accurate?

Answer 15

Ultraviolet light A (UVA) penetrates the dermis.

UVA penetrates the dermis.

Question 16

wound classifications

Answer 16

integrity of skin
- open or closed

cause

• Intentional: surgery, radiation therapy
• Unintentional: accident

description
- Arterial ulcer, Pressure injury, Gunshot wound

depth
- Superficial, Partial thickness, Deep or full-thickness

healing time
- acute or chronic

contamination level
- clean or dirty

Question 17

classification skin integrity

Answer 17

open
- Skin is broken, such as in a cut, puncture, or surgical incision.
Other examples include pressure injuries or ulcers on the skin from vascular diseases.
These wounds can be prone to infection.

closed
- The skin is not broken (intact), for example, a bruise or a hematoma.
Closed wounds can be just as serious as open wounds.
Some wounds that allow the skin to remain intact can cause serious injury internally. A nurse cannot judge the severity of the injury or tissue damage by whether the wound is open or closed.

Question 18

wound depth

Answer 18

superficial and partial thickness
- Superficial wounds affect only the top layer of skin (epidermis).
Partial-thickness wounds extend through the epidermis to the dermis but do not penetrate the subcutaneous layer.
Superficial and partial-thickness wounds generally heal quickly without scarring unless factors, such as infection, interrupt the healing process.

deep
Deep wounds injure all layers of the skin: the epidermis, dermis and subcutaneous layer.
Full-thickness wounds can penetrate the bone, muscle, or other structures.
These wounds usually heal slowly and form scar tissue, and they can even become a chronic type of wound.

Question 19

contamination level

Answer 19

see

Question 20

classifications burns

Chemicals, heat, radiation, electricity, and frostbite can cause burns. If a patient is burned over a large portion of the body, infection and fluid and electrolyte imbalances can be severe. Burns, like wounds, have classifications.

Answer 20

superficial
- Injures the epidermis, causing pain, redness (which will blanch), and no edema

partial thickness
-Injures the epidermis and part (called superficial-partial thickness) or all (called full or deep-partial thickness) of the dermis, leading to blisters, redness, and extreme pain

full thickness
-Injures all three layers, causing the tissue to be dry, white, brown, charred (black); causes no pain (nerves were burnt in injury); requires surgery

Question 21

stages pressure injury (1-4)

Pressure injuries, caused by pressure from bony prominences and/or shearing and friction, can damage the skin to varying degrees. Pressure injuries are classified by type of visible tissue. This is also called staging.

Answer 21

stage 1
- Intact skin with no blisters
Nonblanchable erythema or persistent redness in the area of pressure (abnormal reactive hyperemia)
Painful area that differs in firmness and temperature from surrounding tissues

stage 2
-Partial-thickness wound involving the top two layers of skin: epidermis and dermis
Wound bed that is shallow, superficial, and pink
Includes intact or ruptured blisters from pressure that have not yet cratered

stage 3
-Full-thickness wound extending into the subcutaneous tissue (third layer of skin), but not into fascia, muscle, or bone
Possible undermining (tissue loss around edges and under intact skin, which forms a lip around the wound)
May include tunneling, also called a sinus tract (narrow channel extending from wound)

stage 4
- Full-thickness wound that is deeper than a stage 3 wound
Involves exposure of muscle, bone, tendons, and cartilage
Infection of the bone (osteomyelitis), if exposed, likely to occur

unstagable
- Full-thickness wound with necrotic tissue (eschar)
Inability to assess wound depth or involvement of underlying tissues
Removal of necrotic tissue necessary before staging occurs

suspected deep tissue injury
-Area of intact skin with purple or maroon area or a blood-filled blister
Similar to stage 1 injuries but difficult to detect in darker-skinned patients
Depth of tissue damage not readily visible on observation
Progresses rapidly, exposing deeper layers of tissue damage, even if treated rapidly and correctly

Question 22

types healing

Answer 22

primary intention
- Healing that is swift and uncomplicated in an acute wound with minimal scar tissue

secondary intention
- Healing that starts from the bottom and sides of the wound until new tissue fills the wound bed; larger amounts of tissue loss that take longer to heal

tertiary intention
- Healing in which the wound is initially left open, causing a delay between injury and closure

Question 23

phases wound healing

Wounds progress through several phases. How quickly healing occurs can be affected by complicating factors, such as comorbidities, depth of wound, and wound contamination. The three phases of wound healing are inflammatory, which includes hemostasis (forming clot); proliferative; and maturation/remodeling.

Answer 23

inflammatory
proliferative
maturation/remodeling

Question 24

inflammatory phase

Answer 24

• This phase starts with the body’s initial recognition of and response to a wound—bleeding.
  Bleeding activates the coagulation cascade, which involves platelets releasing growth factors to form a clot and stop bleeding (hemostasis).
  Growth factors, in conjunction with cytokines, are also released during this phase, which initiates wound healing.
  Blood vessels dilate, leaking fluid into the area of injury (wound), resulting in the classic signs of inflammation: pain, redness (erythema), warmth, swelling, and limited function in the area of injury.
  Macrophages and neutrophils move into the area of injury and begin the process of removing bacteria and debris, which cleans the wound bed for the repair process.
  The inflammatory phase lasts approximately 3 days.

Question 25

proliferative phase

Answer 25

Healing and repair are primary processes that occur.
Wound bed fills with new tissue (granulation tissue), resurfacing wound with skin.
Fibroblasts are the primary cells with many functions:
Manufacture growth factors
Combine collagen and proteins to form granulation tissue
Stimulate angiogenesis (creation of new blood vessels) to provide the new tissue with oxygen and nutrients
Pull wound edges together to decrease the quantity of granulation needed
Granulation tissue bleeds easily, and it has a beefy red, granular, bumpy texture; it is not as strong as regular skin.
For the epithelial cells to migrate across the wound and promote epithelialization, a moist, vascular environment is needed.
The proliferative phase lasts several weeks; it can be shorter or longer, depending on depth of wound.

Question 26

maturation/remodeling phase

Answer 26

Collagen continues to be laid down in the wound bed.
If the wound is deep enough, scar tissue is formed and strengthened, but scar tissue only reaches 80% of tissue’s original tensile strength.
The maturation/remodeling stage lasts up to a year.

Question 27

complications

Answer 27

hemorrhage
infection
dehiscence and evisceration
fistula

Question 28

hemorrhage

Answer 28

internal bleeding from injury, removal dislodge clot, loosened stitches

results
Causes the following from excessive bleeding:
Shock: increased pulse and respirations with low blood pressure; medical emergency
Internal effect: swelling and hardness of injured area
External effect: bloody saturation of entire dressing that can drain onto bed linens or pool under the patient

Question 29

inflammation

Answer 29

slow healing When left open or contaminated, increases risk for microorganism invasion

Can cause the following:
Lengthy inflammatory phase
Hindered production of collagen
Inadequate or no epithelialization, which can lead to further tissue damage
Halted or slowed progression of expected wound-healing phases
Possibility of becoming a chronic wound
May require aggressive treatment if current treatment of wound produces no progress

Question 30

dehiscence/evisceration

Answer 30

Dehiscence: partial or complete separation of tissue layers
Evisceration: total separation of tissue layers, allowing protrusion of visceral organs through incision
Generally happens 5 to 9 days after surgery and is correlated with decreased collagen production

Can occur when healing tissues of surgical incision are under physical stress or increased pressure/strain on incision such as obesity and coughing
Lack of a “healing ridge” increases occurrence of these complications (healing ridge: a 1-cm-wide ridge located near incision, which indicates collagen is being produced)

Can include symptoms:
Dehiscence: “popping” sensation with increased drainage from wound
Evisceration: same as dehiscence with internal organs showing, usually bowels (if occurs, cover with moist sterile saline gauze and notify health care provider; medical emergency)

Question 31

fistula

Answer 31

Is an abnormal linking between two body organs or between a body organ and the skin
Can affect both genders
Can be identified by names of organs involved:
Enterovaginal: channel between the intestines (entero) and the vagina; intestinal contents flow into the vagina (see image)
Enterocutaneous: channel between the intestines (entero) and the skin (cutaneous); caustic intestinal content and digestive enzymes flow onto the skin, quickly making the skin prone to breakdown

Usually results from:
Certain diseases, such as cancers and Crohn disease (intestinal disease)
Radiation therapy
Factors of poor wound healing

Can lead to the following:
Loss of fluid and electrolytes, causing imbalances and deficits in nutrition
Damage to skin
Loss of fluid and electrolyte integrity

Question 32

Which phase of wound healing is characterized by a patient who reports that the bumpy and granular injured site “bleeds easily”?

Answer 32

Proliferative
The proliferative phase is the phase of healing and repair in which new tissue bleeds easily and has a granular and bumpy texture.

Question 33

Match the type of wound to its typical colors.

**need to fix

Answer 33

Purple or maroon Suspected deep-tissue injury
White, brown, or black Infected wound
Beefy red and bumpy Full-thickness burn
Red and purulent Wound in proliferative phase

Question 34

Which factors can directly cause the fibroblasts and collagen to be altered or ineffective in the proliferative phase of wound healing?

Answer 34

Prolonged decrease of oxygen perfusion to skin
A prolonged decrease of oxygen perfusion to the skin reduces the production of cells that produce collagen (fibroblasts) and decreases collagen formation.
Correct

Lack of protein
A lack of protein would directly affect collagen because protein is needed for fibroblasts to make collagen.
Correct

Lack of vitamin C
A lack of vitamin C would directly affect collagen because vitamin C is needed for collagen formation.

History of diabetes
Diabetes leads to a decrease in collagen synthesis and strength. Thus, diabetes directly affects collagen.

Question 35

Which cells join the epidermis and dermis and are arranged in a single layer?

Answer 35

Basal cells

Basal cells compose a single layer of active cells that join the epidermis and dermis.

Question 36

Match the type of healing to its characteristic.

Answer 36

Healing is from the bottom and sides of the wound.
Secondary intention
Edges are approximated.
Primary intention
There is a delay between injury and closure.
Tertiary intention

Question 37

Which characteristics of aging cause the skin to be fragile, loose, dry, and transparent?

Answer 37

Loss of elastin
Gradual loss of elastin causes skin to age and become loose.

A decrease in the number of sweat glands
A decrease in the number of sweat glands causes dry skin.

A smoothing of the layer of skin under the epidermis
A smoothing of the layer of skin under the epidermis causes skin to become more fragile.

Question 38

Which response is likely when a patient who has a full-thickness wound receives a steroid?

Answer 38

Healing time will slow.
Steroids, which are antiinflammatories, interrupt the inflammatory process, making patients prone to infections and slow healing.

Question 39

Which characteristic accurately describes the dermis?

Answer 39

Is an area for sebaceous glands

Sebaceous (oil) glands are located in the dermis

Question 40

Which strategy would the nurse use to classify a burn?

Answer 40

According to the skin layer damaged
Classifying the burn according to the skin layer damaged is a common strategy, and the categories include superficial, partial thickness, and full thickness.

Question 41

Which features describe the subcutaneous layer of skin?

Answer 41

Provides insulation to protect against both heat and cold
The subcutaneous layer does provide insulation to protect against both heat and cold.
Correct

Cushions bony prominences and internal organs
The subcutaneous layer does provide cushioning for bony prominences and protection of internal organs.

Question 42

Which nutrients would need to be increased in the diet of a patient with full-thickness burns?

Answer 42

Zinc
Zinc is essential for healing the skin that is burned.
Correct

Copper
Copper is needed for healing of the skin.
Correct

Protein
Fibroblasts need protein to make collagen.
Correct

Vitamin A
Vitamin A would be needed for healing of the burn.
Correct

Vitamin C
Vitamin C would be needed for collagen formation.

Question 43

Which classification would the nurse use for staging a pressure injury that has a full-thickness wound and extends into the subcutaneous tissue, but not into the fascia, muscle, or bone?

Answer 43

Stage 3
Stage 3 pressure injuries are characterized by full-thickness wounds that extend into the subcutaneous tissue, but not into the fascia, muscle, or bone.

Question 44

Which type of opening occurs in a patient who has an enterocutaneous fistula?

Answer 44

Between the skin and the intestine
An opening between the skin and the intestines is described as enterocutaneous. “Entero” means intestines, and “cutaneous” means skin.

Question 45

Which complication would the nurse identify for the health care provider in a patient whose surgical incision “popped” open and is draining fluid?

Answer 45

Dehiscence
Dehiscence is a partial or complete separation of tissue layers and includes a “popping” sound with an increase in drainage. This accurately describes the scenario

Question 46

Which processes occur in the proliferative phase of wound healing?

Answer 46

Stimulation of angiogenesis
Stimulation of angiogenesis occurs in the proliferative phase to provide the new tissue with oxygen and nutrients.
Correct

Creation of granulation tissue
Creation of granulation tissue occurs in the proliferative phase to fill in the wound with new cells.

Question 47

Which interpretation would the nurse make about a wound that is colonized?

Answer 47

Contains microorganisms on the surface of the wound only
A colonized wound contains one or more microorganisms on the surface of the wound, with no clinical signs of a wound infection.

Question 48

Which classic signs would the nurse observe in a wound that is in the inflammatory phase of healing?

Answer 48

Swelling
Swelling would occur in the inflammatory phase.
Correct

Erythema
Erythema is a classic sign that occurs in the inflammatory phase of wound healing.