Skin Integrity and Wound Healing Overview
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Questions and Answers

Which layer of the skin houses blood vessels, hair follicles, sweat glands, and nerve fibers?

  • Dermis (correct)
  • Hypodermis
  • Subcutaneous layer
  • Epidermis

What is NOT one of the main functions of the skin?

  • Thermoregulation
  • Protection
  • Sensation
  • Communication (correct)

Which of the following conditions is a skin disorder that stems from an allergic reaction?

  • Blisters
  • Melanoma
  • Cellulitis
  • Contact dermatitis (correct)

What is the main objective of the hemostasis phase in wound healing?

<p>To stop any bleeding (D)</p> Signup and view all the answers

Which factor is NOT mentioned as contributing to delayed wound healing?

<p>Poor nutrition (B)</p> Signup and view all the answers

What term describes the state of the skin when it is undamaged and healthy?

<p>Skin integrity (B)</p> Signup and view all the answers

Which phase of wound healing involves the body’s defense mechanism to kill bacteria?

<p>Inflammation (A)</p> Signup and view all the answers

Which factor is NOT typically considered a risk factor for impaired skin integrity?

<p>Skin color (A)</p> Signup and view all the answers

Which symptom is a sign of localized wound infection?

<p>Erythema (A)</p> Signup and view all the answers

Which phase of wound healing involves the formation of new tissue and blood vessels?

<p>Proliferative phase (A)</p> Signup and view all the answers

What is one common sign of wound infection?

<p>Increased warmth around the wound (A)</p> Signup and view all the answers

During the proliferation phase, which of the following processes occurs first?

<p>Filling the wound with new connective tissue (D)</p> Signup and view all the answers

Which nursing intervention is most effective in promoting wound healing?

<p>Frequent assessment and changing of dressings (C)</p> Signup and view all the answers

Which factor related to diabetes contributes to delayed wound healing?

<p>Neuropathy (B)</p> Signup and view all the answers

What is the final phase of wound healing that involves strengthening new tissue?

<p>Maturation (B)</p> Signup and view all the answers

How does stress affect wound healing?

<p>It impairs immune response (C)</p> Signup and view all the answers

What does skin integrity primarily refer to?

<p>The maintenance of healthy, intact skin (B)</p> Signup and view all the answers

Which of the following is NOT considered an intrinsic risk factor for impaired skin integrity?

<p>Environmental pollutants (D)</p> Signup and view all the answers

How does diabetes increase the risk of skin breakdown?

<p>It causes poor circulation and neuropathy (D)</p> Signup and view all the answers

What role do vitamins play in skin health?

<p>They support tissue repair and skin health (C)</p> Signup and view all the answers

What is a consequence of impaired mobility concerning skin integrity?

<p>Higher risk of pressure ulcers (A)</p> Signup and view all the answers

Which skin condition is known for weakening the skin barrier?

<p>Psoriasis (B)</p> Signup and view all the answers

How does obesity affect skin integrity?

<p>It increases pressure on skin folds (A)</p> Signup and view all the answers

What is the primary cause of shear forces in the skin?

<p>Layers of skin sliding over each other (C)</p> Signup and view all the answers

What is a primary consequence of prolonged pressure on bony prominences?

<p>Tissue ischemia leading to pressure ulcers (D)</p> Signup and view all the answers

Which of the following conditions can result from prolonged exposure to moisture on the skin?

<p>Maceration and skin breakdown (C)</p> Signup and view all the answers

How does the use of corticosteroids affect wound healing?

<p>Thins the skin and impairs healing (C)</p> Signup and view all the answers

What is the impact of excessive sweating on the skin?

<p>Creates a moist environment that weakens the skin barrier (B)</p> Signup and view all the answers

Which systemic factor is NOT associated with impaired wound healing?

<p>Proper nutrition (C)</p> Signup and view all the answers

What local factor does NOT directly affect wound healing?

<p>Patient's age (B)</p> Signup and view all the answers

What effect can harsh cleaners have on the skin?

<p>Damages the skin (A)</p> Signup and view all the answers

Which environmental factor can lead to skin irritation?

<p>Cold weather (B)</p> Signup and view all the answers

What is a primary action for preventing pressure ulcers in patients?

<p>Daily skin assessments (A)</p> Signup and view all the answers

Which patient group is considered high risk for pressure ulcers?

<p>Elderly and immobile patients (C)</p> Signup and view all the answers

What is the recommended frequency for repositioning a patient with a pressure injury?

<p>At least every two hours (A)</p> Signup and view all the answers

Which action is most appropriate for minimizing risk in patients with neuropathy?

<p>Recommending well-fitting shoes (B)</p> Signup and view all the answers

What is an effective method to relieve pressure on bony prominences?

<p>Repositioning every 2 hours (B)</p> Signup and view all the answers

Which of the following is recommended for moisture management in patients?

<p>Immediate cleaning after incontinence episodes (D)</p> Signup and view all the answers

What intervention is effective in controlling edema for patients with venous ulcers?

<p>Using compression dressings (C)</p> Signup and view all the answers

For optimal healing of arterial ulcers, what is the common recommendation regarding extremity positioning?

<p>The extremity should be kept flat (C)</p> Signup and view all the answers

What role do barrier creams play in skin care?

<p>They protect against moisture and irritation (A)</p> Signup and view all the answers

What is a key dietary concern for patients with chronic wounds?

<p>Adequate nutrition and hydration (C)</p> Signup and view all the answers

Which of the following vitamins is crucial for supporting skin healing?

<p>Vitamin C (D)</p> Signup and view all the answers

What is a significant consideration when caring for diabetic patients?

<p>Monitor for signs of neuropathy (A)</p> Signup and view all the answers

Which stage of pressure injury is characterized by partial-thickness loss of skin with exposed dermis?

<p>Stage 2 (C)</p> Signup and view all the answers

Why is interdisciplinary collaboration important in skin care?

<p>It helps develop comprehensive care plans (D)</p> Signup and view all the answers

Which of the following is NOT a risk factor for developing pressure ulcers?

<p>Excessive hydration (A)</p> Signup and view all the answers

What should be done if there are concerns about the healing of a chronic wound?

<p>Communicate concerns to the healthcare provider (C)</p> Signup and view all the answers

Flashcards

Epidermis

The outermost layer of skin composed of tightly packed epithelial cells.

Dermis

The inner layer of skin containing blood vessels, hair follicles, and nerves.

Hypodermis

The layer beneath the dermis containing connective tissue and stored fat.

Thermoregulation

The ability of the skin to maintain the body's core temperature within a certain range.

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Sensation

The skin's function allows sensing touch, pain, and temperature.

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Contact Dermatitis

An inflammatory skin condition caused by contact with an allergen.

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Blister

A localized fluid-filled sac on the skin.

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Skin Cancer

Unwanted growths on the skin, some can be cancerous.

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What is Skin Integrity?

Maintaining healthy, intact skin that acts as a barrier against external threats like infections, chemicals, and injury.

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How does Aging affect Skin Integrity?

Reduced collagen and elastin make skin thinner and more delicate. Less cushioning over bony areas leads to higher pressure injury risk. Healing slows down.

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How does Diabetes impact Skin Integrity?

Diabetes can cause poor circulation and nerve damage, increasing risk of skin breakdown, especially on feet.

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What is the impact of Prolonged Pressure on Skin?

Prolonged pressure on bony areas (e.g., sacrum, heels) reduces blood flow, leading to tissue damage and pressure ulcers.

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How do Skin Conditions affect Skin Integrity?

Conditions like Eczema or Psoriasis cause inflammation, weakening the skin barrier.

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How does Body Weight impact Skin Integrity?

Obesity increases pressure on skin folds, restricts blood flow. Low body weight reduces cushioning over bony areas.

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What are some External Threats to Skin Integrity?

Factors like infections, harsh chemicals, and extreme temperatures can compromise skin integrity.

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What are Extrinsic Risk Factors for Skin Integrity?

They are related to the external environment, care practices, or mechanical forces.

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Shear Force

Force that occurs when layers of skin slide over each other, damaging blood vessels and tissues. Think of sliding down in bed.

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Friction

Friction happens when skin rubs against a surface, like bed linens, causing abrasions.

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Incontinence

Prolonged exposure to urine or feces can cause skin breakdown, making the skin soft and easily damaged.

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Excessive Sweating

Excessive sweating creates a moist environment, weakening the skin's protective barrier.

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Wound Drainage

Fluid from wounds can irritate surrounding skin, making it more prone to breakdown.

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Poor Hygiene

Using soaps with high pH levels, abrasive materials, or inadequate cleaning practices can damage the skin.

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Medical Devices

Devices such as tubes, catheters, or oxygen masks, can cause pressure or friction injuries on the skin.

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Environmental Factors

Extreme heat and humidity can lead to increased sweating and skin irritation. Cold weather dries the skin, making it more prone to cracking.

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What is a pressure injury?

A pressure injury is damage to the skin or tissues caused by prolonged pressure, often on bony areas, which restricts blood flow and leads to tissue breakdown.

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Stage 1 Pressure Injury

Stage 1 pressure injuries involve redness of the skin that doesn't fade when pressed, meaning the tissue is getting damaged.

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Stage 2 Pressure Injury

Stage 2 pressure injuries involve partial thickness skin loss, exposing the dermis or inner layer of skin.

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Stage 3 Pressure Injury

Stage 3 pressure injuries involve full thickness skin loss, exposing fat but not deeper structures like bone.

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Stage 4 Pressure Injury

Stage 4 pressure injuries involve full thickness skin loss with exposed bone, muscle, or tendons.

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Which risk factor makes someone more prone to pressure injuries?

Lack of movement, like being bedridden, can increase the risk of pressure injuries because it puts pressure on the same areas for a long time.

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How does nutrition affect pressure ulcers?

Poor nutrition doesn't give the body the building blocks it needs to repair damaged tissue, making it more susceptible to pressure injuries.

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How does diabetes impact pressure injuries?

Diabetes can damage blood vessels and nerves, impairing blood flow and sensation, making someone more prone to pressure injuries.

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Hemostasis

The initial phase of wound healing aimed at stopping bleeding. It involves activation of the blood clotting system to form a clot, preventing further blood loss and initiating wound closure.

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Inflammation

The second phase of wound healing, focused on cleaning the wound and removing debris. It involves the activation of the immune system, deploying white blood cells to kill bacteria and clear out dead cells.

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Proliferation

The third phase of wound healing where the wound is filled, edges are pulled together, and new tissue is formed. This involves the growth of connective tissue and blood vessels, contraction of wound edges, and formation of a protective barrier.

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Maturation

The final phase of wound healing where the newly formed tissue strengthens and gains flexibility. This involves remodeling of collagen fibers and improvement in the overall structure of the wound.

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Diabetes and wound healing

A condition affecting many body systems, including wound healing. It causes delayed wound healing due to poor circulation, neuropathy, and impaired immunity, leaving individuals more vulnerable to infection.

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Stress and wound healing

A state of mental or emotional strain that can negatively impact wound healing. It weakens the immune system, leading to delayed healing and increased susceptibility to infections.

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Smoking and wound healing

A significant factor affecting wound healing, characterized by impaired inflammation, leading to slower healing and increased risk of infection. It can also affect the other phases of wound healing.

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Atherosclerosis and wound healing

A condition affecting wound healing due to poor blood flow, which can lead to delayed healing and increased risk of infection. Impaired oxygenation and nutrient supply hinder the body's ability to repair damaged tissues.

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What is Regular Skin Assessment?

Regularly inspecting the skin for changes like redness, swelling, or breaks. It helps flag early signs of pressure ulcers.

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What are Risk Assessment Tools?

Tools like the Braden Scale and Norton Scale are used to assess a patient's risk of developing pressure ulcers based on factors like mobility, sensory perception, and moisture.

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What is Repositioning?

Turning and repositioning patients every 2 hours or as needed to relieve pressure on bony areas like the heels, hips, and tailbone.

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What are Support Surfaces?

Using special mattresses or cushions to distribute pressure evenly and prevent skin breakdown in areas with higher pressure.

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How does Nutrition Impact Skin Integrity?

Ensuring patients get enough fluids and foods rich in protein, vitamins, and minerals to aid in skin healing and prevent breakdown.

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What is the Role of Moisturizers?

Applying moisture-rich creams or lotions to prevent skin from drying out and cracking, which can lead to breakdown.

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Why are Barrier Creams Used?

Use of zinc oxide or dimethicone-based creams to protect the skin from moisture and friction, especially in areas prone to incontinence or wound drainage.

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What is Patient and Family Education?

Educating patients and their families about the importance of skin care, repositioning, and nutrition to help prevent pressure ulcers and promote healthy skin.

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Study Notes

Skin Integrity and Wound Healing

  • Skin is composed of two main layers: epidermis and dermis
  • Epidermis is the outermost, thin layer of closely packed epithelial cells
  • Dermis is the inner, thick layer containing blood vessels, hair follicles, sweat glands, and nerve fibers
  • Hypodermis lies beneath the dermis, containing connective tissue and adipose tissue (fat) connecting skin to underlying bones and muscles
  • Skin has three main functions:
    • Protection from mechanical, thermal, physical injuries, harmful agents, moisture, protein loss, and UV radiation
    • Thermoregulation of body temperature
    • Sensation (responds to touch, feeling and pain)

Conditions Affecting Skin

  • Allergies (e.g., contact dermatitis)
  • Blisters
  • Bug bites (spider, mosquito)
  • Skin cancer (melanoma)
  • Skin infections (cellulitis)
  • Skin rashes
  • Skin disorders (acne, eczema, psoriasis, vitiligo)
  • Wounds, burns (sunburns), and scars

Definition of Skin Integrity

  • Skin integrity is maintaining healthy, intact skin that functions as a protective barrier to external threats (pathogens, chemicals, physical injury).
  • It ensures the preservation of skin's structure, function, and ability to repair itself after damage.

Risk Factors for Impaired Skin Integrity

  • Intrinsic (internal) factors:
    • Age-related changes: thinning skin, reduced collagen/elastin, decreased subcutaneous fat, slower healing
    • Chronic medical conditions: diabetes (poor circulation, neuropathy, especially in feet), vascular diseases (peripheral artery disease-PAD), immunosuppression (HIV, chemotherapy), renal failure (dry skin)
  • Extrinsic (external) factors:
    • Pressure: prolonged pressure on bony prominences (sacrum, heels) reduces blood flow, leading to ischemia and pressure ulcers
    • Shear and friction: sliding down in a bed, damaging blood vessels/tissues, or rubbing against surfaces causing abrasions
    • Moisture: extended exposure to urine/feces causing maceration & skin breakdown, excessive sweating creating moist environment weakening skin barrier, wound drainage irritating surrounding skin
    • Poor hygiene: inadequate cleaning leading to irritation/infection, harsh cleansers damaging skin
    • Medical devices: pressure/friction injuries from tubes, catheters, or oxygen masks
    • Environmental factors: heat/humidity causing excessive sweating, cold weather drying skin, causing cracking.

Factors Affecting Wound Healing

  • Local factors:
    • Localized blood flow
    • Tissue oxygenation
    • Presence of infection, foreign body
    • Venous insufficiency
  • Systemic factors:
    • Age, obesity, malnutrition, medications (corticosteroids), alcohol consumption, smoking, stress -Diabetes (neuropathy, atherosclerosis, decreased immune resistance)

Phases of Wound Healing

  • Hemostasis: stopping bleeding by activating blood clotting, forming a scab (first step)
  • Inflammation: killing bacteria, removing debris using white blood cells, ensuring wound cleanliness, preparing for tissue growth
  • Proliferation: filling wound with new connective tissue/blood vessels, contracting wound edges, epithelial cells covering wound (creating protective barrier between inside/outside)
  • Maturation: strengthening and building flexibility of new tissue.

Signs of Wound Infection

  • Erythema (redness)
  • Induration (hardened tissue)
  • Pain
  • Edema
  • Purulent exudate (yellow/green drainage)
  • Wound Odor

Nursing Care to Promote Wound Healing

  • Minimize pressure/shear on bony prominences; reposition patients
  • Educate patients about injury prevention, using appropriate footwear
  • Control edema with compression dressings
  • Promote adequate blood flow
  • Manage blood glucose levels.
  • Manage nutritional status (calories, proteins, vitamins.)
  • Monitor wound healing.
  • Document assessment and interventions.
  • Communicate and collaborate with other healthcare providers

Pressure Ulcer (Stages)

  • Stage 1: Localized, non-blanchable erythema (redness), prolonged pressure
  • Stage 2: Partial-thickness skin loss with exposed dermis
  • Stage 3: Full-thickness skin loss; fat is visible, but cartilage, tendon, ligament, muscle or bone not exposed
  • Stage 4: Full-thickness tissue loss; cartilage, tendon, ligament, muscle, or bone exposed

Risk Factors of Pressure Ulcers

  • Immobility
  • Incontinence
  • Decreased sensory perception
  • Nutritional deficiency (protein, fluids, minerals)
  • Medical conditions affecting blood flow

Nursing Interventions to Protect Skin Integrity

  • Conduct regular skin assessments; inspect daily for redness, swelling, dryness or breakdown
  • Use validated tools (Braden scale, Norton Scale) to assess pressure ulcer risk
  • Identify high-risk patients (elderly, immobile, critically ill, diabetics, incontinent, malnutrition)
  • Pressure ulcer prevention: repositioning, support surfaces (pillows, mattresses, air mattresses), avoiding shear and friction
  • Moisture management
  • Adequate nutrition and hydration
  • Collaboration with other professionals (dietitians, therapists)
  • Patient and family education

Special Considerations in Nursing Interventions

  • Diabetic patients: monitor signs of neuropathy/poor circulation, assess for foot problems, regular foot checkups and proper footwear.
  • Elderly patients: address age-related skin changes (thinning, reduced elasticity)
  • Critically ill patients: use advanced support surfaces, monitoring early pressure ulcer signs

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Skin Integrity and Wound Healing PDF

Description

This quiz covers essential concepts of skin anatomy, including the layers of the skin, their functions, and the various conditions affecting skin integrity. It also delves into skin disorders and the impact of wounds and healing processes. Test your understanding of skin health and its critical roles in the human body.

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