Skin Integrity

Question 1

Layers of the skin

Answer 1

Epidermis- outer layer
Dermis- middle vascular layer with glands

Subcutaneous- connective and adipose tissue.

Question 2

Contamination

Answer 2

All chronic wounds are contaminated.

Because they have microorganisms in the wound.

Question 3

3 phases of wound healing

Answer 3

Inflammation
Proliferation
Maturation

Question 4

Clean wounds

Answer 4

Uninfected with minimal inflammation.
Can be open or closed.
But does not involve respiratory, GI, or UI tract

Question 5

Clean-contaminated wounds

Answer 5

Surgical incisions that enter the GI,respiratory , or UI tract

Risk of infection but not seen yet

Question 6

Contaminated wounds

Answer 6

Open traumatic wounds, or incisions with a major break in asepsis

Question 7

Infected wound

Answer 7

Over 100k bacteria organism per gram of tissue.
Any amount of beta-hemolytic streptococci is an infection.

Question 8

The 3 thickness depths of wounds

Answer 8

Superficial- only the epidermal layer, usually friction, shearing or burning

Partial- thickness- through epidermis but not the dermis.

Full-thickness- extends to subcutaneous tissue and farther

Question 9

Types of Healing

Answer 9

Regenerative/epithelial: affects only epidermis and some dermis. No scar forms.

Primary intention: minimal tissue loss, well approximated edges. Little scaring, good surgical incision.

Secondary intention: extensive tissue loss prevents approximation, should not be closed due to infection. Heals bottom up, with granulation tissue(connective) some pearl epithelial areas.

Tertiary intention: occurs when two granulation tissue is brought together. Occurs after secondary, with aseptic technique.

Question 10

Phases of healing

Answer 10

Inflammatory phase- cleansing
1-5days includes
Homeostasis- vessels constrict, platelets aggregate. Clotting mechanism begin.
Inflammation- edema, erythema, pain, temperature elevation, migration of WBCs, phagocytosis and plasma proteins and fibrin scabs.

Proliferation phase- granulation
Days 5-21
Fibroblasts migrate to wound to become collagen. Growth of blood vessels. Scab dissolves to become epithelial tissue.

Maturation phase- epithelialization.
Remodeling after wound closes to turn collagen fibers to strong scar tissue.

Question 11

Collaborative wound treatments

Answer 11

Surgical options- grafts, debridement, flap techniques.

Hyperbaric oxygen therapy- increases WBC function, increases vessel formation

Platelet-derived growth factor: accelerates collagen formation

Question 12

Types of wound drainage

Exudate(pus) serum, fibrin, leukocytes

Answer 12

Serous exudate-
watery w/little cellular matter. Straw colored fluid that separates out of blood when clot is formed. Typical of clean wounds

Sanguineous exudate-
Bloody drainage. Sign of damaged capillaries. Usually deep wounds. Fresh is bright red, old is dark red-brown.

Serosanguineous exudate-
Combo bloody and serous, new wounds.

Purulent exudate-
thick, often malodorous, found in infected wounds. Contains pus that can be yellow or bluish- green depending on bacteria.

Purosanguineous exudate-
Red tinged pus. It indicates that small vessels in the wound area have ruptured.