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Skin Integrity

Fundamentals of Nursing

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