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Skin Integrity
Fundamentals of Nursing
| Question | Answer |
|---|---|
| What is the largest organ in the body? | The skin |
| What are the two layers of the skin? | Epidermis and dermis |
| Which layer of the epidermis consists of cells that proliferate and move toward the surface? | Basal layer |
| Which layer of the epidermis consists of keratinized cells? | Stratum corneum |
| Which layer of the skin provides tensile strength? | Dermis |
| What does the dermis contain? | Collagen, blood vessels, and nerves |
| What is the only distinctive cell of the dermis? | Fibroblasts |
| What is a localized injury to skin and other underlying tissue, usually over a bony prominence, as a result of pressure in combination with shear and/or friction? | A pressure ulcer |
| What are some age-related changes to the skin? | Reduced skin elasticity, decreased collagen, and thinning of underlying muscle and tissue |
| Why is epithelization and wound healing slow in aging adults? | A diminished inflammatory response |
| What are characteristics of a Stage I pressure ulcer in a dark-skinned individual? | An eggplant color; edema may occur with induration adn appear taut and shiny; tissue on palpation is boggy and mushy |
| What is a Stage I pressure ulcer? | Unblanchable redness, usually over a bony prominence |
| What is a Stage II pressure ulcer? | Partial-thickness skin loss |
| Describe a Stage II pressure ulcer. | Loss of dermis presents as a shallow, open ulcer with a red-pink wound bed. |
| True or False: A Stage II pressure ulcer has slough. | False |
| What is a Stage III pressure ulcer? | Full-thickness skin loss |
| Describe a Stage III pressure ulcer. | Subcutaneous fat may be visible |
| True or False: In a Stage III pressure ulcer, bone, tendon, and muscle are visible. | False |
| True or False: In a Stage IV pressure ulcer, bone, tendon,muscle, and subcutaneous fat are visible. | True |
| What does excessive wound exudate indicate? | Infection |
| How will suspected deep tissue injury present? | A purple or maroon localized area of discolored intact skin |
| Describe primary intention wound healing. | Skin edges are approximated and risk of infection is low. |
| How do primary intetion wounds heal? | From the top down |
| Describe secondary intention wound healing. | The wound is left open until it fills with scar tissue. |
| How do secondary intetion wounds heal? | From the inside out |
| What are the three components of partial-thickness wound repair? | Inflammatory response, epithelial proliferation and migration, and reestablishment of epidermal layers |
| How long does it take a wound left open to air to resurface? | 6-7 days |
| How long does it take a wound kep moist to resurface? | 4 days |
| Why does a wound that is kept moist heal faster than one left open? | Because epidermal cells only migrate across a moist surface |
| What are the four phases of full-thickness wound repair? | Hemostasis, inflammatory phase, proliferative phase, and maturation |
| What occurs during hemostasis? | Injured blood vessels constrict and platelets gather to stop bleeding |
| What is secreted during the inflammatory phase? | Histamine |
| When does the proliferative phase begin? | With the appearance of new blood vessels |
| How long does the proliferative phase last? | 3-24 days |
| What occurs during the proliferative phase? | The wound contracts, fills with granulation tissue, and resurfaces |
| What color is granulation tissue? | Pink or red |
| What can cause an impairment in the proliferative phase? | Age, anemia, hypoproteinemia, and zinc deficiency |
| How long does the maturation phase take? | Can take place for more than 1 year |
| True or False: A healed wound has more tensile strength than the tissue it replaces. | False |
| What is a hematoma? | A localized collection of blood underneath tissues |
| What is dehiscence? | Partial or total separation of wound layers |
| Where is dehiscence common? | In abdominal surgical wounds |
| What is evisceration? | Protrusion of visceral organs through a wound opening |
| What is the first step if a patient presents with evisceration? | Place a sterile gauze soaked in sterile saline over the prodtruding tissues. |
| What are other nursing interventions for a patient presenting with evisceration? | Contact the surgical team, make sure the patient is NPO, monitor for S/S of shock, and prepare for emergency surgery |
| What is the caloric intake for patients who have undergone surgery? | 1500 kcal/day |
| What are important nutrients required for wound healing? | Protein, vitamins (especially A and C), zinc, and copper |
| What delays the inflammatory response in the elderly? | Decreased function of macrophages |
| If a wound has a dressing over it and the provider has NOT ordered it to be changed, should you remove the bandage to inspect the wound? | No it should not, unless you suspect serious complications |
| What are the types of wound drainage? | Serous, sanguineous, serosanguineous, and purulent |
| True or False: You can collect a wound culture from old drainage. | False |
Created by:
shrewsbury_sd
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