Chapter 32: Skin Integrity and Wound Healing

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Questions and Answers

What is the primary function of the epidermis?

To provide cushioning around vital organs.

To connect the skin to muscles and bones.

To produce new skin cells for healing.

To act as a barrier against environmental factors. (correct)

Which layer of the skin is responsible for producing new cells?

Stratum granulosum

Stratum lucidum

Stratum corneum

Stratum germinativum (correct)

What role does the subcutaneous layer play?

It contains the nerves and blood vessels.

It serves as a protective barrier.

It produces sweat and oil.

It helps to insulate the body and cushion vital organs. (correct)

Which factor does NOT affect skin integrity?

Body weight Signup and view all the answers

What is the consequence of immobility on skin integrity?

It can lead to increased pressure on tissues. Signup and view all the answers

Which nutrient is NOT mentioned as essential for maintaining skin health?

Iron Signup and view all the answers

What condition can result from dehydration of the skin?

Increased vulnerability to injury Signup and view all the answers

Which statement about the dermis is true?

It contains hair follicles, oil and sweat glands. Signup and view all the answers

What characterizes a deep tissue injury?

It shows persistent, non-blanchable discoloration. Signup and view all the answers

What is a requirement for determining the stage of an unstageable pressure ulcer?

Eschar must be removed from the wound bed. Signup and view all the answers

What is a critical nursing intervention to prevent pressure injuries?

Repositioning patients every 2 hours. Signup and view all the answers

What type of skin care is essential for maintaining skin integrity in patients at risk for pressure injuries?

Consistent cleansing and moisturizing practices. Signup and view all the answers

How does nutrition play a role in the prevention and healing of pressure injuries?

Adequate protein and calorie intake supports tissue repair. Signup and view all the answers

What is a potential consequence of diminished sensation in clients?

Risk of burns or wounds going unnoticed Signup and view all the answers

Which factor can contribute to the development of pressure injuries in clients with impaired cognition?

Decreased awareness of the need to reposition Signup and view all the answers

How does impaired circulation affect tissue health?

It leads to muscle atrophy and skin breakdown Signup and view all the answers

Which of the following is a common effect of fever on the skin?

Greater vulnerability to maceration Signup and view all the answers

What best describes a closed wound?

A bruise without skin breakage Signup and view all the answers

Which type of wound healing is associated with significant tissue loss?

Secondary intention healing Signup and view all the answers

What characterizes contaminated wounds?

High risk due to a major break in asepsis Signup and view all the answers

What is a defining feature of superficial wounds?

Injury primarily affecting the epidermis Signup and view all the answers

Which type of wound healing is likely to create less scarring than secondary, but more than primary intention?

Tertiary intention healing Signup and view all the answers

Which is NOT a characteristic of chronic wounds?

Heal spontaneously Signup and view all the answers

What phase of wound healing occurs first and involves hemostasis and inflammation?

Inflammatory phase Signup and view all the answers

Which of the following medications can interfere with skin integrity?

Antihistamines Signup and view all the answers

Which condition increases the metabolic demand for oxygen in tissues?

Hyperthermia Signup and view all the answers

What is the main role of platelets in the initial wound healing process?

To slow down the bleeding by clumping together Signup and view all the answers

Which phase of wound healing occurs between days 5 to 21?

Proliferative phase Signup and view all the answers

What type of drainage indicates an infection?

Purulent drainage Signup and view all the answers

What complication is characterized by the total separation of wound layers, requiring immediate attention?

Dehiscence Signup and view all the answers

Which pressure ulcer stage involves non-blanchable erythema of intact skin?

Stage 1 Signup and view all the answers

What is the potential outcome of poor nutritional status during wound healing?

Increased risk of dehiscence Signup and view all the answers

Which scale assesses the risk for impaired skin integrity based on six specific factors?

Braden scale Signup and view all the answers

What condition does ischemia refer to in wound healing?

Tissue lack of adequate blood flow and oxygen Signup and view all the answers

During which stage of healing do macrophages start to clear debris and engulf bacteria?

Inflammatory phase Signup and view all the answers

What is the color characteristic of serosanguinous drainage?

Pinkish hue Signup and view all the answers

Which factor does NOT increase the risk of wound dehiscence?

Excessive weight lifting post-surgery Signup and view all the answers

What is the consequence of chronic drainage from a fistula?

Delays in wound healing Signup and view all the answers

What is a key sign of infection in a wound?

Localized redness and heat Signup and view all the answers

During which phase does the remodeling of collagen fibers occur?

Maturation phase Signup and view all the answers

Study Notes

Skin Integrity and Wound Healing

Skin is the body's largest organ, acting as a protective barrier.
Composed of three layers: epidermis, dermis, and subcutaneous layer.

Epidermis

Forms the primary barrier.
Visible cells shed from deeper layers.
Stratum germinativum (basal layer) is the deepest, closest to blood supply.
Continuously produces new cells, pushing older cells to the surface for shedding.

Dermis

Contains connective tissue, blood vessels, glands (oil and sweat), nerves, and hair follicles.

Subcutaneous Layer

Provides insulation and cushioning for organs.

Factors Affecting Skin Integrity

Age: Infants, children, and older adults have thinner, more permeable skin, increasing risk of breakdown. Immobility, friction/shearing, moisture, poor nutrition, decreased perfusion, and altered consciousness increase risk for pressure injuries.
Nutrition: Adequate protein, vitamins C, zinc, and copper are crucial for collagen formation and healing. Dry or edematous skin is vulnerable to injury.
Sensation: Diminished sensation reduces awareness of injury, potentially leading to burns, cuts, wounds, and pressure sores.
Level of Consciousness (LOC): Impaired cognition (e.g., Alzheimer's, dementia) predisposes individuals to pressure injuries due to lack of awareness about repositioning needs.
Impaired Circulation: Restricts activity, causes pain, results in muscle atrophy, thin tissue easily impacted by ischemia and necrosis; impaired venous circulation causes edema, ulceration, and breakdown. Both forms delay wound healing.
Medications: Some medications can cause skin issues (itching, rashes, photosensitivity, alopecia, pigment changes) that impact integrity and healing.
Moisture: Exposure (e.g., incontinence, fever) leads to maceration (softening) and breakdown.
Fever: Increases metabolic rate, raising tissue oxygen demand. Difficult to meet if there are circulatory issues or tissue compression. Infection, toxins, and invasions increase tissue metabolic demand.
Skin Infection: Increases vulnerability to breakdown and hinders healing.
Lifestyle: Tanning, frequent bathing with harsh soaps, infrequent cleansing can impair skin barrier and increase issues. Body piercing/tattoos increase risk of infection & scarring.

Wound Classification

Closed Wounds: No break in skin (e.g., contusions, bruises, fracture-related swelling).
Open Wounds: Break in skin or mucous membranes (e.g., abrasions, lacerations, punctures).
Acute Wounds: Expected short duration, heal spontaneously (inflammation, proliferation, maturation).
Chronic Wounds: Heal beyond expected time.
Clean Wounds: Uninfected, minimal inflammation.
Clean/Contaminated Wounds: Surgical incisions entering GI, respiratory, or GU tracts; increased infection risk, but no infection present.
Contaminated Wounds: Open traumatic wounds or surgical incisions with compromised asepsis. High infection risk.
Infected Wounds: Bacteria count over 100,000 per gram or presence of beta-hemolytic streptococci indicates infection.
Superficial Wounds: Involve epidermis only (e.g., friction burns).
Partial-Thickness Wounds: Extend through epidermis but not dermis.
Full-Thickness Wounds: Extend into subcutaneous tissue & potentially beyond (can be described as penetrating).

Wound Healing Processes

Primary Intention: Minimal tissue loss; edges well-approximated; little scarring (e.g., clean surgical incision).
Secondary Intention: Extensive tissue loss; edges can't be approximated; heals from inner layers to surface; slower, more prone to infection, more scarring (e.g., pressure injuries, infected wounds).
Tertiary Intention: Delayed primary closure; wound initially heals by secondary intention, then edges are closed when infection/edema risk is gone.
Phases of Wound Healing
- Inflammatory Phase (Cleansing): lasts 1-5 days; hemostasis (stopping bleeding) and inflammation (edema, erythema, pain).
- Proliferative Phase (Granulation): Days 5-21; filling the wound with collagen-producing fibroblasts, blood vessels/lymph vessels grow, epithelial cells cover the wound.
- Maturation Phase (Remodeling): Weeks to months; collagen remodeled, scar tissue forms, increasing wound strength.

Wound Drainage

Serosanguinous: Pinkish, mix of serous (clear) and sanguineous (bloody) drainage.
Purulent: Thick, yellow/green/brown, indicates infection.
Sanguinous: Bloody, indicates active bleeding.
Puro-sanguinous: Red-tinged pus, indicates ruptured vessels in wound likely infected.

Wound Healing Complications

Hemorrhage: Increased risk in first 24-48 hours.
Infection: Localized swelling, redness, pain, temp > 100.4°F, foul odor, change in drainage color.
Dehiscence: Wound layer separation.
Evisceration: Internal organs protrude through wound (surgical emergency).
Fistula Formation: Abnormal passage connects body cavities; often results from infection.

Nursing Assessment of Skin and Wounds

Focused Skin Assessment: Gather data on age, mobility, nutrition, hydration, sensation, circulation, lifestyle.
Braden Scale: Evaluates risk factors for pressure injuries (sensory perception, moisture, activity, mobility, nutrition, friction, shear). Lower scores correlate with higher risk.
Norton Scale: Assesses risk based on physical/mental state, activity, mobility, and incontinence; lower scores indicate higher risk.

Pressure Injuries

Staging Pressure Ulcers:
- Stage 1: Non-blanchable erythema of intact skin.
- Stage 2: Skin breaks open to deeper layers (ulcer formation).
- Stage 3: Ulcer extends through dermis, into subcutaneous tissue.
- Stage 4: Full-thickness tissue loss; exposed bone/tendon/muscle.
- Deep Tissue Injury: Non-blanchable, deep red/purple discoloration.
- Unstageable: Covered by eschar; depth cannot be determined; eschar needs to be removed before staging.
Nursing Interventions:
- Prevention (paramount)
- Meticulous skin care
- Adequate nutrition
- Frequent repositioning

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Test your knowledge on the structure of skin and factors affecting its integrity. This quiz covers the layers of skin, their functions, and how various conditions impact wound healing and skin health. Ideal for nursing and healthcare students.