Skin integrity and wound care

Question 1

list the Functions of skin

Answer 1

Protection, sensitivity, thermal regulation, excretion and secretion

Question 2

list the skin layers

Answer 2

epidermis, dermis and subcutaneous tissue

Question 3

list some possible causes of wounds

Answer 3

trauma, surgery, sustained pressure, vascular disease, infection, etc

Question 4

mention the main types of wound

Answer 4

1. Acute wounds: they progress through normal signs of wound healing and show signs of healing within four weeks. e.g. abrasions, lacerations, surgical incisions
2. Chronic wounds: do not progress normally and do not show signs of healing within four weeks. e.g. venous, arterial or diabetic foot ulcers

Question 5

what are the 4 phases of wound healing?

Answer 5

1. Hemostasis phase (purpose is to stop bleeding)
2. Inflammatory phase (purpose is to clean the wound and defend it against bacteria)
3. Proliferative phase (purpose is formation of new tissue)
4. Remodeling phase (purpose is formation of scar)

Question 6

Mention the types of wound healing

Answer 6

1. Primary intention: wound edges remain close together
2. Secondary intention: wounds are left open and allowed to heal by scar formation.
3. Tertiary intention: delayed closure and would is left open to heal by scar formation.

Question 7

list the factors affecting healing process

Answer 7

blood supply, medication, smoking, medication, extent of the injury, nutrition and hydration, infection, advanced age, chronic diseases, products cytotoxic for fibroblasts and pressure off-loading.

Question 8

list wound complications

Answer 8

hemorrhage, infections, fistula, abscess formation, cellulitis, necrosis or gangrene, keloids, pain, fluid collection and interference with organ function.

Question 9

what is pressure injury?

Answer 9

a localized area of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and friction.

Question 10

what are the 4 stages of pressure injury classification?

Answer 10

stage 1: Nonblanchable erythema
stage 2: Partial thickness skin loss with exposed dermis
stage 3: Full thickness skin loss
stage 4: Full thickness tissue loss

Question 11

deep tissue injury

Answer 11

Intact or not intact skin with unblanchable deep red or maroon discolouration revealing
blood filled blister

Question 12

Unstageable pressure injury

Answer 12

Full thickness skin and
tissue loss where the
loss cannot be
determined due to
obscure slough and
eschar

Question 13

what is the evidence-based practice for pressure injury prevention?

Answer 13

ADSD
Assess: Perform and repeat risk assessments regularly and as frequently according to patient’s condition
Document: document all risk assessments
Score: use risk scores to plan care, and perform interventions accordingly
Detect: ongoing skin assessment can detect early signs of pressure damage

Question 14

Interpretation for Braden scale

Answer 14

at risk (15-18)
moderate risk (13-14)
high risk (10-12)
very high risk (<9)

Question 15

what do you consider during a wound assessment?

Answer 15

location, type of wound, type and percentage of tissue in wound base, wound size, wound exudate, presence of odor, wound edge, periwound area, pain and tunneling/undermining

Question 16

what is wound bed preparation?

Answer 16

a systematic approach to cleanse the wound to correct the molecular and cellular abnormalities, which is
critical to promoting healing of chronic wounds

Question 17

what are the 4 key principles for practice during wound bed preparation?

Answer 17

TIME
* Tissue debridement
* Infection/inflammation
* Moisture balance
* Edge of the wound

Question 18

wound care dressing categories

Answer 18

1. Gauze dressings (cotton or synthetic materials, woven or non-woven. To protect surgical or minimally draining wounds or wound-packing. E,g, Curity Gauze Sponges)
2. Transparent film (waterproof adhesive membrane. Best for securing intravenous IV tubing, can visualize wound and skin underneath dressing)
3. Hydrocolloids (gel forming agents. maintain a moist environment, waterproof)
4. Hydrogel (glycerin or water-based polymers)
5. Alginates and Hydrofibre dressings
6. Foam dressings

Question 19

what is the purpose of packing?

Answer 19

to fill dead space and avoid potential abscess formation

Question 20

what is used for undermining or tunnelling?

Answer 20

Gauze impregnated with hydrogel

Question 21

what is used to fill narrow areas?

Answer 21

Ribbon gauze

Question 22

what are pressure bandages?

Answer 22

temporary treatment to control excessive, unanticipated bleeding and to stop blood flow and promote clotting

Question 23

what are abdominal binders?

Answer 23

it supports large abdominal incisions from tension/stress; lessens pain post op. it is elastic or cotton

Question 24

nursing diagnosis

Answer 24

• Inadequate peripheral tissue perfusion
• Insufficient knowledge regarding pressure injury prevention
• Inadequate nutrition
• Reduced mobility
• Reduced skin integrity
• Potential for impaired skin integrity

Question 25

planning

Answer 25

• Establish patient needs and baseline for future assessment
• Identify prevention interventions
• verify patient social support for continuity of care
• relieve anxiety and educate patients

Question 26

Implementation

Answer 26

• Use of evidenced-based guidelines
• Optimal treatment option (types of products)
• Health promotion
• Topical Skin care
• positioning
• support surfaces (therapeutic Beds and Matresses)
• Education
• Management of injury

Question 27

Evaluation

Answer 27

• Reassess skin for signs and symptoms related to impaired skin integrity and wound healing
• check patient’s understanding and perception about skin integrity and intervention
• Check expectations