Skin Integrity and wounds

Question 1

What are the 3 structures of the skin?

Answer 1

Epidermis
Dermis
Subcutaneous

Question 2

Describe the Epidermis

Answer 2

Outer layer of the skin. It is a protective waterproof layer of keratinized cell. The epidermis is not vascularized and it regenerates quickly and easily.

Question 3

Describe the Dermis

Answer 3

Elastic tissue primarily made out of collagen. contains nerves, hair follicles, glands, immune cells, and blood vessels.

Question 4

Describe subcutaneous

Answer 4

Anchors the skin to underlying tissue.

Question 5

What are the important functions of the skin?

Answer 5

Protection
Body temperature regulation
Psychosocial
Sensation
Vitamin D production
Immunologic
Absorption
Elimination

Question 6

What is the first defense of the body against harmful agents?

Answer 6

Unbroken skin.

Question 7

What are some ways our skin change as we get older?

Answer 7

The structure of the skin changes as a person ages; the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin

Older adults: circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure

Question 8

What are the types of wounds that we need to know?

Answer 8

Intentional (surgical) or unintentional (traumatic)
Neuropathic or vascular
Pressure related
Open or closed
Acute or chronic
Partial thickness, full thickness, complex

Question 9

What is an intentional wound?

Answer 9

A wound caused intentionally in a sterile setting for example surgery.

Question 10

What is a unintentional wound?

Answer 10

Wound caused by accident which may require a tetanus shot.

Question 11

What is a Neuropathic or vascular wound?

Answer 11

Related to an underlying neurologic and/or circulatory issue

Question 12

what are the 4 phases of wound healing?

Answer 12

Hemostasis
Inflammatory
Proliferation
Maturation

Question 13

Explain Tertiary intention

Answer 13

The wound is too edematous or infected so the wound is intentionally left open until those issues resolve and then the wound is closed.

Question 14

Explain Hemostasis as part of wound healing

Answer 14

*Occurs immediately after initial injury
*Involved blood vessels constrict and blood clotting begins
*Exudate is formed, causing swelling and pain
*Increased perfusion results in heat and redness
*Platelets stimulate other cells to migrate to the injury to participate in other phases of healing

Hemostasis happens right after the initial injury primarily to stop the bleeding and wake up the white blood cells to fight any invading bacteria.

Question 15

Explain the inflammatory phase.

Answer 15

The inflammatory phase comes right after and lasts about 2 to 3 days. This is when the white blood cells (WBCs), predominantly leukocytes and macrophages, move to the wound. Macrophages are essential to wound healing.
Macrophages enter the wound area and remain for an extended period. They ingest debris and release growth factors that attract fibroblasts to fill in the wound
Exudate is formed and accumulates, causing pain, redness, and swelling at the site of injury
The patient has a generalized body response

Question 16

Is redness, swelling ands pain in itself a cause for concern when a wound is healing?

Answer 16

No, this is a generalized body response and is a normal part of wound healing in the inflammatory phase.

Question 17

Explain the proliferation phase.

Answer 17

Repair is the proliferation phase. This is where the fibroblastic, regenerative, or connective tissue phase encompasses the processes that result in actual healing.
Lasts for several weeks
New tissue is built to fill the wound space through the action of fibroblasts
Capillaries grow across the wound
A thin layer of epithelial cells forms across the wound
Granulation tissue forms a foundation for scar tissue development

Question 18

Explain the maturation phase.

Answer 18

The proliferation phase can last for several weeks. The maturation phase is the very last phase and typically occurs about 3 weeks after the injury and can last for months to years. New collagen shows up, compressing the blood vessels and forming a scar.
Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years
Collagen is remodeled
New collagen tissue is deposited, which compresses the blood vessels in the wound, causing a scar
Scar: flat, thin, white line; avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

Question 19

What are the local factors that can affect skin healing?

Answer 19

Pressure
Desiccation (dehydration)
Maceration (overhydration)
Trauma
Edema
Infection
Excessive bleeding
Necrosis (death of tissue)
Presence of biofilm (thick grouping of microorganisms)

Question 20

What are the systemic factors that can affect healing?

Answer 20

Age: children and healthy adults heal more rapidly
Circulation and oxygenation: adequate blood flow is essential
Nutritional status: healing requires adequate nutrition
Wound etiology: specific condition of the wound affects healing
Health status: corticosteroid drugs and postoperative radiation therapy delay healing
Immunosuppression
Medication use
Adherence to treatment plan

Question 21

What are 4 causes of wound complication?

Answer 21

Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation

Question 22

What is an Dehiscence?

Answer 22

Where a wound is not wanting to close up.

Question 23

What is Evisceration?

Answer 23

Something that is protruding out of the wound.

Question 24

What are factors that affect pressure injury developement?

Answer 24

Aging skin
Chronic illnesses
Immobility
Malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders

Question 25

If the patient have non-blanchable erythema of intact skin, what stage of pressure injury do they have?

Answer 25

Stage 1

Question 26

If the patient has full thickness skin loss which does not involve the underlying fascia, what stage of pressure injury do they have?

Answer 26

Stage 3

Question 27

If the patient have full thickness skin and tissue loss what stage of pressure injury do they have?

Answer 27

Stage 4

Question 28

If the patient have partial- thickness skin loss with exposed dermis, what stage of pressure injury do they have?

Answer 28

Stage 2

Question 29

If the patient have obscured full-thickness skin and tissue loss what stage of pressure injury do they have?

Answer 29

This patient is unstageable

Question 30

If the patient presents with persistent non-blanchable deep red, maroon or purple discoloration. What stage of pressure injury do they have?

Answer 30

This would be deep tissue pressure.

Question 31

At what stage would you see non blanchable erythema?

Answer 31

Stage 2

Question 32

Describe serous drainage.

Answer 32

Clear, watery fluid that leaks from a wound and is made up of plasma, the liquid base of blood

Question 33

Describe Sanguineous drainage.

Answer 33

A normal part of the inflammatory stage of wound healing. Sanguineous drainage is the initial discharge from an open wound that is made up of fresh blood and a clear, yellow liquid called blood serum. It's usually bright red in color and has a syrupy consistency

Question 34

Describe Serosanguineous drainage.

Answer 34

Serosanguineous drainage is the most common type of wound drainage secreted by an open wound in response to tissue damage. It is a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells

Question 35

Describe purulent drainage.

Answer 35

Thick, milky, pus-filled fluid that oozes from a wound and indicates an infection. Usually has a foul odor.

Question 36

What are some things you would do to assess a wound?

Answer 36

Measure the size and depth of the wound. Determine if there is presence of undermining, tunneling or sinus tract.

Question 37

What is tunneling/sinus tract of a wound?`

Answer 37

A tunneling wound is a chronic wound that forms a channel or tunnel that extends from the surface of the skin into deeper tissue. The tunnel can be short or long, shallow or deep, and may create pockets or dead-end passages within the wound

Question 38

What are some ways that pressure injuries can be avoided/prevented?

Answer 38

Assess at risk patients daily Cleanse the skin routinely Maintain higher humidity; use moisturizers Protect skin from moisture Minimize skin injury from friction or shearing Proper positioning, turning, transferring Appropriate support surfaces Nutritional supplements Improve mobility and activity

Question 39

A person with wounds should eat a diet ______ in _______ for optimal healing.

Answer 39

High in protein.