NR224 Exam 2 Study Guide

NR224 Exam 2 Study Guide

CH 48: Skin Integrity and Wound Care

1.Describe the dermis and the epidermis.Dermis: The dermis, the inner layer of the skin, provides tensile strength; mechanical support; and protection for the underlying muscles, bones, and organs. It differs from the epidermis in that it contains mostly connective tissue and few skin cells.Collagen (a tough, fibrous protein), blood vessels, and nerves are found in the dermal layer.Fibroblasts, which are responsible for collagen formation, are the only distinctive cell type within the dermis.Epidermis: The epidermis, or the top layer, has several layers. The stratum corneum is the thin, outermost layer of the epidermis. It consists of flattened, dead, keratinized cells. The cells originate from the innermost epidermal layer, commonly called the basal layer. Cells in the basal layer divide, proliferate, and migrate toward the epidermal surface. After they reach the stratum corneum, they flatten and die. 1185This constant movement ensures replacement of surface cells sloughed during normal desquamation or shedding.

2.What are three pressure related factors that contribute to pressure ulcers? Why?Three pressure-related factors which contribute to pressure ulcer development: 1. Intensity 2. Duration 3. Tissue Tolerance

These can be caused by:

Major cause is PRESSURE!Impaired mobility Decreased/impaired sensory perception Fecal and/or urinary incontinence Poor nutrition Aging skin Presence of a cast Alteration in the level of consciousness

Moisture 

3.Describe the following terms:

a.Granulation tissue: Granulation tissue is red, moist tissue composed of new

blood vessels, the presence of which indicates progression toward healing.b.Slough: Soft yellow or white tissue (stringy substance attached to wound bed), and it must be removed by a skilled clinician or with the use of an appropriate wound dressing before the wound is able to heal.c.Eschar: Black, brown, tan, or necrotic tissue,which needs to be removed before healing can proceed.d.Exudate: Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes.e.Necrotic tissue: pertaining to the death of tissue in response to disease or injury.

4.Describe friction & shear.Friction: Effects of rubbing or the resistance that a moving body meets from the surface on which it moves; a force that occurs in a direction to oppose movement.Shear: Force exerted against the skin while the skin remains stationary and the bony structures move. Occurs when there is a change in position due to gravity. Muscle and bone slide in the direction of body movement. Tissue damage occurs deep in the tissues causing undermining of the dermis. It affects the epidermis/top layer of skin (unlike shear injuries).

5.What is the Braden scale and why do we use it? The interpretation of the meaning of the total numerical scores differs with each risk- assessment scale relevant to their population.Lower numerical scores on the Braden Scale indicate that the patient is at high risk for skin breakdown.A benefit of the predictive instruments is to increase a nurse's early detection of patients at greater risk for ulcer development. Once you identify these patients, institute appropriate interventions to maintain skin integrity and implement prevention strategies

Perform reassessment for pressure ulcer risk on a scheduled basis.The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development 6.A HOB of _30__ degrees or less reduces pressure on the coccyx and helps reduce pressure ulcers. (HOB means head of the bed)

7.Explain the following methods of wound healing & give examples of each:

a.Primary intention: Primary union of the edges of a wound, progressing to

complete scar formation without granulation. (wound is closed)

b.Secondary intention: Wound closure in which the edges are separated;

granulation tissue develops to fill the gap; and, finally, epithelium grows in over the granulation, producing a larger scar than results with primary intention.(wound edges not approximated) c.Tertiary intention: Wound that is left open for several days; then wound edges are approximated -Which one is the most effective for wound healing? Primary intention, healing occurs quickly with a fine scar and minimal infection 8.Describe the different stages of pressure ulcers (1-4).Stage I- Intact skin with non-blanch able redness of a localized area usually over a bony prominence Stage II- partial-thickness skin loss of dermis/blister. Presents as a shallow open ulcer with a red pink wound bed, without slough.Stage III- full thickness skin loss (fat visible) Slough may be present but does not obscure the depth of the tissue loss. May be undermining and tunneling.Stage IV – full thickness tissue loss with exposed bone/tendon/muscle. Slough or eschar may be present. Often includes undermining and tunneling.

Unstageable/Unclassified: Full thickness skin/-depth unknown. Suspected deep-tissue injury that is purple or maroon in color in a localized area of discolored intact skin. May be a blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear 9.What are nursing interventions to help prevent pressure ulcers? Promoting the

following concepts:

Mobility – frequency of position changes. Reduces pressure and shearing forces Nutritional status – loss of 5% of usual weight, less than 90% of ideal body weight or decrease of 10 pounds in a brief time are all signs of actual/potential nutrition problems Body Fluids – continuous/frequent exposure (urine, bile, stool, purulent exudates, gastric, etc.) Pain – willingness/ability to move Multidisciplinary approach Adequate nutrients Relief of pressure Wound should be reassessed for location, size, tissue type, and amount, exudate and surrounding skin condition Use skin sealant or moisture-barrier ointment on surrounding skin Secure dressing with the least amount of tape possible 10.How does urinary incontinence lead to ulcers?Because the patient has a hard time controlling his/her bladder, the skin will constantly be moist. If they already have an open wound, the bacteria from the urine can cause infection.Urinary incontinence should be controlled with proper diet and medications.

11.What is the differences between an abrasion, laceration, and a puncture?Abrasion: is superficial with little bleeding and is considered “partial-thickness” wound Laceration: sometimes bleed more profusely. It greater than 5 cm long or 2.5 cm deep

Puncture: internal bleeding and infection can occur.

****If any of these occur, determine if the patient has had a tetanus shot within the last 5yrs****