Skin Integrity Exam 2 Flashcards
What is the outer portion of the skin called?
Epidermis
Contains melanocytes, keratinocytes, and Langerhans cells.
What lies below the epidermis and above subcutaneous tissue?
Dermis
Provides strength and elasticity to the skin.
What provides insulation, protection, and a reserve of calories in the event of severe malnutrition?
Subcutaneous Tissue
Composed of connective and adipose tissues.
What are some factors affecting skin integrity?
- Age- older adults not enough liquids
infants- cant regulate temp - Impaired Mobility
- Nutrition and Hydration
- Diminished Sensation or Cognition
- Impaired Circulation
- Medications
- Lifestyle
- Moisture
Protein, cholesterol
Each factor can lead to alterations in skin integrity.
What is the effect of decreased protein levels on skin integrity?
Fluid leaks from vascular space to dependent areas leading to edema
This interferes with skin elasticity and oxygen diffusion.
What happens to older adults’ sebaceous and sweat glands?
They diminish, leading to dry skin
Skin layers thin due to environmental effects and loss of elasticity.
Fill in the blank: An abnormal passage connecting two body cavities or a cavity and the skin is called a _______.
Fistula
Often results from infection or debris left in the wound.
What is the primary intention of wound healing?
Minimal or no tissue loss with edges well approximated
Results in little scarring.
What is the inflammatory phase of wound healing characterized by?
- Blood vessel dilation
- White blood cell activity
- Fibrin plug formation
- Growth factor release
- Cytokine activity
This phase helps clean up the wound.
What is a key feature of the proliferative phase in wound healing?
Granulation tissue forms
New blood vessels grow and epithelialization occurs.
What is evisceration?
Total separation of layers of the wound
It is a surgical complication and an emergency.
What should be done if evisceration occurs?
Cover the wound with sterile saline soaked sterile towels
Call the physician and prepare for surgery.
What are the types of drains used in wound care?
- Penrose Drain
- Hemovac
- Jackson-Pratt (JP) drain
Hemovac and JP drains are typically placed to suction.
What is debridement?
Removal of devitalized tissue or foreign material from a wound
It helps stimulate wound healing.
What are the types of debridement?
- Sharp Debridement
- Mechanical Debridement
- Enzymatic Debridement
- Biotherapy (Maggot) Debridement
Each type has specific methods and applications.
What is the Braden Scale used for?
Assessing a client’s risk for alterations in skin integrity
It evaluates factors like mobility and nutrition.
What is a common cause of wound dehiscence?
- Inadequate nutrition
- Inadequate closure of muscles
- Increased tension at suture line
- Obesity
- Diabetes
- Infection
These factors can lead to separation of wound layers.
True or False: All chronic wounds are contaminated.
True
Contamination refers to the presence of bacteria.
What should be done if a drain has stopped draining?
Assess for occlusion
Check facility policy regarding ‘milking’ drains.
What is the appearance of slough in a wound?
White, yellow, tan, stringy or loose, adherent to wound bed
It requires debridement.
What are signs and symptoms of infection in a wound?
Fever, increased pain, redness, swelling, and discharge
These signs may appear after surgery.
What is the ideal volume for irrigation of a wound?
50 to 100 mL per centimeter of length
This volume helps ensure proper cleansing.
What types of medications can affect skin integrity?
- Photosensitivity
- Alopecia
- Pigmentation changes
- Dermatoses
- Pruritus
These effects can arise from various medications.
What is Mechanical Debridement?
Techniques such as wet to dry dressings, whirlpool therapy, hydrotherapy
Mechanical debridement involves physical methods to remove dead tissue.
What is Enzymatic Debridement?
Use of enzymatic creams to break down necrotic tissue without affecting viable tissue around the wound
Enzymatic debridement is a selective method that targets dead tissue.
What is Biotherapy (Maggot) Debridement?
Medical grade larvae dissolve dead and infected tissues from wounds by secreting enzymes that break down dead tissue
The larvae are changed every 48-72 hours and disposed of in biohazard medical waste bags.
How does Biotherapy (Maggot) Debridement ensure healthy tissue remains unharmed?
The enzymes secreted by the larvae are neutralized so healthy tissue remains unharmed
This method is effective but can be emotionally disturbing to clients.
What is Leech therapy used for?
Wound management requiring frequent changes
Leech therapy helps in blood circulation and can assist in healing.
What type of dressings should be used around IV catheters and CVCs?
Transparent, occlusive dressings
These dressings help protect insertion sites and reduce infection risk.
What is Negative Pressure Wound Therapy?
Wound Vac that suctions bacteria and stimulates regeneration
This therapy promotes healing by creating a negative pressure environment.
What signs indicate a wound is healing?
Less redness, less drainage
Monitoring these signs is crucial in wound assessment.
What laboratory results should the nurse review to assess antibiotic effectiveness?
Less WBC on labs
A decrease in white blood cell count can indicate effective treatment.
What labs may the nurse want to review if the patient is on prolonged antibiotic therapy?
Therapeutic levels of antibiotics
Monitoring for potential toxicity or side effects is important in prolonged therapy.
Younger skin has more what compared to older skin?
more collagen
EXAM
Factor affecting skin integrity
Protein!
helps with wound healing and foundation to repair skin.
Protein lowers blood sugar with diabetes
N/A
Wounds heal inside to out
Secondary Intention
wet to dry dressing
What happens during the inflammatory phase?
Clean up, blood vessels dialate, WBC increase
Proliferative growth phase
Granulation tissue forms:A new tissue made of collagen and other proteins replaces the provisional fibrin matrix
New blood vessels grow:Capillaries replace damaged vessels to restore circulation
Epithelialization occurs:New skin forms over the wound
Maturation phase
Collagen production:Collagen is remodeled from type III to type I, and the collagen fibers cross-link to reduce scar thickness
Wound contraction:Myofibroblasts, a type of fibroblast, contract to close the wound edges
Apoptosis:Unneeded cells are removed through programmed cell death
Scar tissue:A buildup of collagen in the granulation tissue forms new scar tissue
What is hemorrhage?
hemostasis usually occurs within minutes of injury
When are clients most at risk for hemorrhage?Internal Hemorrhage – Swelling, hematoma may be present
Why would a hematoma be dangerous?External Hemorrhage
What is infection?
What are s/s of infection in a wound?
When would the client show s/s of infection after surgery?
Fever, redness, drainage, smell, sweat
What is dehiscence?
separation of one or more layers of a wound
use waist binder, often due to smoking, obesity and lack of nutrition
What is evisceration?
EMERGENCY
is total separation of layers of the wound. It is a surgical complication. SOAK in sterile solution/ towels to prevent drying out
A nurse needs to chart within how many hours of admission for wounds?
24h
Slough
white, yellow, tan, stringy or loose, adherent to wound bed - Debride
Eschar
necrotic tissue, dry, thick, leathery, black, brown, or gray - Debride
What is the Braden scale for wounds?
EXAM:
example, patient has a score of 5, what intervention?
determine risk for pressure uclers
What interventions?
-barriers
-scuds
-protein
-dry skin
-nutrition
-movement
Swabbing, tissue biopsy, and needle aspiration can be used to identify pathogens.
An Xray, CT, or MRI may be needed to assess how deep the infection is. Infection involving the bone or muscle may require specialized treatment or amputation.
What are other labs associated with new or chronic wounds?
WBC, hemoglobin, lactic acid
What is lactic acid? organ failure
What does it indicate?septis
Would the nurse draw labs or get cultures before or after administering antibiotics? Before
Diabetic ulcer vs staged wound
Staged vs upstaged wound
Wound interventions
swab, clean, send sample of to lab. Apply dressing. call wound nurse stage 2 or more
isotonic solution
normal saline
What PPE should be worn during irrigation?
face shield
Penrose drain
small tube, not structured
Jackson pratt drain or called hemovac
1 intervention- remove take off cap, no suction
placed to suction
Remove suction when draining
Drains
Serous Wound
straw colored
Serous- sanguineous Wound
yellow/red
Sanguineous Wound
Bloody
purulent Wound
pus infection
Tissue in wound bed
Slough and Eschar
Granulation tissue – Pink to red moist tissue, pebble like – Clean and protect
Nongranulating tissue – absence of granulation but pink and shiny – Promote tissue growth, keep clean
Epithelial - regenerating epidermis, pink, pearly white – Clean and protect
