Skin Integrity & Wounds

Question 1

What are factors affecting skin integrity?

Answer 1

Factors affecting skin integrity include:
* Age - For older adults, epidermal cell maturation is delayed, leading to thin, easily damaged skin. Circulation and collagen formation are also impaired, leading to decreased elasticity and increased risk for tissue damage from pressure
* Adequate circulation
* Nutrition
* Hydration
* Mobility
* Chronic diseases
* Medications
* Moisture levels
* Friction and shear

Question 2

What changes occur in the skin related to older adults?

Answer 2

Changes in skin related to older adults include:

Older adults: circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure. The subcutaneous and dermal tissues becoming thinner, the activity of the sebaceous and sweat glands decreases, cell renewal is shorter, melanocytes (cells that make the pigment that colors hair and skin) decline in number, and the collagen fiber is less organized.

• Thinning of the epidermis
• Decreased elasticity
• Increased dryness
• Slower wound healing
• More fragile skin (thin skin)

Question 3

How are wounds classified according to the accepted classification system?

Answer 3

Wounds are classified based on:
* Intentional (surgical) or unintentional (traumatic)
*Neuropathic or vascular
*Pressure related
*Open or closed
*Acute or chronic
*Partial thickness, full thickness, complex

Question 4

What is the normal process of wound healing?

Answer 4

The normal process of wound healing includes:
* Hemostasis
* Inflammation
* Proliferation
* Maturation

Question 5

What factors affect wound healing?

Answer 5

• The person’s age, disease process, comorbidities, genetic factors, etc., may help or hinder the wound-healing process. The local factor is related to the wound itself and may be hindered by pressure, dehiscing, maceration, trauma, bleeding, infection, necrosis, etc*

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

Question 6

What are common wound complications?

Answer 6

Common wound complications include:
* Infection
* Hemorrhage
* Dehiscence (dehydration)
* Evisceration ( is the most serious complication of dehiscence. It occurs primarily with abdominal incisions. The abdominal wound completely separates, with protrusion of viscera (internal organs) through the incisional area. Patients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining)

Question 7

What factors are involved in pressure injury?

Answer 7

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

Question 8

How is pressure injury categorized based on the accepted staging system?

Answer 8

Pressure injury is categorized based on:
* Stage I (non-blanchable erythema of intact skin)
* Stage II (partial thickness skin loss with exposed dermis)
* Stage III (full thickness skin loss; not involving underlying fascia)
* Stage IV (full thickness skin and tissue loss)
* Unstageable (obscured full-thickness skin and tissue loss)
* Deep tissue pressure injury: persistent nonblanchable deep red, maroon, or purple discoloration

Question 9

What should be included in a care plan for a patient with impaired skin integrity?

Answer 9

A care plan for a patient with impaired skin integrity should include:
* Assessment of skin condition
* Regular repositioning
* Skin care regimen
* Nutritional support
* Education on skin protection

Question 10

Differentiate types of wound dressings/products.

Answer 10

-Those that maintain moisture
-Those that absorb moisture
-Those that add moisture

Question 11

Epidermis

Answer 11

-Protective waterproof layer of keratin
-Cells have no blood vessels of their own
-Regenerates easily and quickly

Question 12

Dermis

Answer 12

-Elastic tissue made primarily of collagen
-Nerves, hair follicles, glands, immune cells, and blood vessels

Question 13

Subcutaneous

Answer 13

Anchors the skin layers to underlying tissues

Question 14

Functions of the Skin

Answer 14

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

Question 15

What are some causes of skin alterations?

Answer 15

-Very thin and very obese people are more susceptible to skin injury (more susceptible to skin irritation and injury)

-Fluid loss during illness causes dehydration and predisposes skin to breakdown (fever, vomiting, or diarrhea reduce the body’s fluid volume. This is fluid volume deficit or dehydration (depending on its intracellular and/or intravascular and sodium losses) and makes the skin appear loose and flabby)

-Jaundice causes yellowish, itchy skin (excessive bile in lightly pigmented skin, causes the skin to feel itchy and dry; patients with jaundice are more likely to scratch their skin and cause an open lesion, with the potential for infection)

-Diseases of the skin, such as eczema and psoriasis, may cause lesions that require special care (may have a genetic predisposition and can often cause lesions requiring special care)

Question 16

Types of wounds: Incision

Answer 16

Cutting or sharp instrument; wound edges well approximated and aligned; surrounding tissue undamaged; bleeds freely and least likely to become infected

Question 17

Types of wounds: Incision

Answer 17

Cutting or sharp instrument; wound edges well approximated and aligned; surrounding tissue undamaged; bleeds freely and least likely to become infected

Question 18

Types of wounds: Contussion

Answer 18

Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma

Question 19

Types of wounds: Abrasion

Answer 19

Friction; rubbing or scraping epidermal layers of skin; top layer of skin scraped away; dirt and germs often embedded and can become infected

Question 20

Types of wounds: Laceration

Answer 20

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue; frequently contaminated with dirt or other material ground into the wound and likely to become infected

Question 21

Types of wounds: Puncture

Answer 21

Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental; consider penetrating object when considering infection probability

Question 22

Types of wounds: Penetrating

Answer 22

Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues

Question 23

Types of wounds: Avulsion

Answer 23

Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Question 24

Types of wounds: Chemical

Answer 24

Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

Question 25

Types of wounds: Thermal

Answer 25

High or low temperatures; cellular necrosis as a possible result

Question 26

Types of wounds: Irradiation

Answer 26

Ultraviolet light or radiation exposure; can cause wet or dry desquamation

Question 27

Types of wounds: Pressure ulcers

Answer 27

Compromised circulation secondary to pressure or pressure combined with friction; classified by Stages 1–4, Unstageable, and Deep Tissue injury

Question 28

Types of wounds: Venous ulcers

Answer 28

Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction; frequently have significant drainage; compression essential (after arterial flow verified)

Question 29

Types of wounds: Arterial ulcers

Answer 29

Injury and underlying ischemia, resulting from a lack of blood flow to the lower extremities secondary to conditions such as atherosclerosis or thrombosis; many have black eschar; increasing blood flow essential for treatment

Question 30

Types of wounds: Diabetic ulcers

Answer 30

Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure; located below the ankle

Question 31

Whats hemostasis?

Answer 31

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

-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

Question 32

Whats the Inflammatory Phase?

Answer 32

• 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*

-Follows hemostasis and lasts about 2 to 3 days
-White blood cells, predominantly leukocytes and macrophages, move to the wound
-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 33

Whats the Proliferation Phase?

Answer 33

• 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 34

Whats the Maturation Phase?

Answer 34

• 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 35

Identify factors affecting wound healing:
Systemic Factors Affecting Wound Healing

Answer 35

-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 36

Identify factors involved in pressure injury

Answer 36

-External pressure compressing blood vessels
-Friction or shearing forces tearing or injuring blood vessels
-Microclimate: temperature and moisture of the skin