48 Skin Integrity and Wound Care
How much does the skin constitute for?
Largest organ in the body (15% of total body weight)
When the skin is injured what is the function of the epidermis and dermis?
-The epidermis functions to resurface the wound and restore barrier against invading organisms -The dermis responds to restore the structural integrity (collagen) and physical properties of skin
What is the normal capillary pressure range?
15 to 32 mmHg
A nurse is changing the dressing of a client with a drain placed at the surgical site. The nurse notices that the collecting device has minimal drainage, which is much less than expected. What does the nurse suspect based on this observation? 1. Accelerated wound healing 2. Need for advancing the drain 3. Dislodged tube of the drain 4. Blockage in the drainage tube
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The nurse is teaching a group of nursing students about the role of nutrients in wound healing. Which statements are correct? Select all that apply. 1. Fats are the most essential elements for tissue repair and growth. 2. Protein needs are increased and are essential for tissue repair and growth. 3. Trace elements are required for epithelialization and collagen fiber linking. 4. Calories provide the energy source needed for cellular activities involved in wound healing. 5. A balanced intake of protein, fat, carbohydrates, vitamins, and minerals is critical to support wound healing.
A balanced nutritional intake promotes wound healing. Protein needs especially are increased and are essential for tissue repair and growth. Collagen is a protein and is a critical component in wound healing. Calorie requirements are high to provide the energy for cellular activity in wound healing. If calories are deficient, the body starts breaking down fats for energy, which may be detrimental for wound healing. A balanced intake of various nutrients such as protein, fat, carbohydrates, vitamins, and minerals is important for wound healing. Trace elements like zinc and copper are required for epithelialization and collagen fiber linking. Fats have no role in wound healing. 2,3,4,5
Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface
A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing 4
The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which clients would be at increased risk of wound dehiscence? Select all that apply. 1. A malnourished client 2. An obese client 3. A young adult 4. A female client 5. A client with wound infection
A malnourished client may have poor wound healing which may lead to wound dehiscence. Obesity may increase strain on surgical incisions. In addition, fat tissue has poor wound healing. Infection interferes with the wound healing process and may increase the risk of wound dehiscence. A young adult may have a better wound healing and has less risk of wound dehiscence. Gender may not affect wound healing and dehiscence. 1,2,5
A nurse is performing an admission assessment on a client who is paralyzed due to a stroke. The nurse notices a redness of the skin in the sacral area. What characteristics of the skin and surrounding tissues help the nurse to classify the wound as stage I pressure ulcer? Select all that apply. 1. Cyanotic skin changes 2. Warm edematous skin 3. Cooler than the adjacent tissue 4. Generalized blanchable erythema 5. Localized nonblanchable erythema
A stage I pressure ulcer is described as a localized area of nonblanchable erythema, more often over a bony prominence. The skin in the affected area can be warm, edematous, hard, firm, or painful. The adjacent tissue may be cooler or warmer than the affected area. The nurse should pinch the skin to check whether the edema blanches and check the skin changes in relation to the adjacent tissue. Cyanotic or blue-colored skin may indicate necrosis of the underlying tissue, which is not associated with a stage I pressure ulcer. Generalized edema is not a characteristic of a pressure ulcer. 2, 3, 5
What is collagen?
A tough fibrous protein, blood vessels and nerves found in there dermal layer (formed from fibroblasts found in dermis)
For a client who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive diaper
An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed. Test-Taking Tip: Remember the "RICE" acronym for acute injuries: Rest, Ice, Compression, Elevation. Although clients may prefer warmth, ice is more appropriate and it helps with pain. 2
A nurse assesses an elderly client admitted to the hospital after a fall. What assessment findings could place the client at risk of developing pressure ulcers? Select all that apply. 1. The client has urinary incontinence. 2. The client suffers from hypertension. 3. The client is immobilized due to a leg fracture. 4. The client has impaired sensory perception. 5. The client is confused but can express pain and discomfort.
Clients with urinary incontinence who cannot take care of personal hygiene have prolonged exposure to moisture. This can soften the skin, making it more susceptible to ulcer formation. Immobility also puts a client at a risk of pressure ulcers as the client cannot move voluntarily to relieve pressure from affected body parts, causing prolonged pressure. Clients with impaired sensory perception are not able to feel or express pain and discomfort in the areas under pressure. Hypertension does not put a client at risk for pressure ulcer development. A client who can express pain and discomfort is at a low risk of developing ulcers as he or she can verbalize about painful areas. 1,3,4
A dark-skinned hospitalized client is bedridden. While examining the client, which characteristics will determine that the client has developed a pressure ulcer? Select all that apply. 1. The skin color remains unchanged on application of pressure. 2. The localized area of the skin appears purple. 3. There is blanching of the skin. 4. The area of the skin with a pressure ulcer appears darker. 5. As the tissue changes color, the intact skin becomes warm.
Dark-skinned clients have different characteristics of skin when integrity is lost. The color of the skin remains unchanged on application of pressure. The localized area of the skin appears purple or blue instead of red. Blanching of the skin does not occur in dark-skinned clients. The area of the skin with a pressure ulcer appears lighter than the surrounding area. In addition, as the tissue changes color, the intact skin becomes cool. 1, 2
How does the dermis differ from epidermis?
Dermis is composed of mostly connective tissue and few skin cells
The nurse understands that exposure of skin to body fluids increases the risk of skin breakdown and pressure ulcers. Which body fluids pose a high risk for skin breakdown? Select all that apply. 1. Gastric drainage 2. Pancreatic drainage 3. Saliva 4. Bile 5. Urine
Gastric and pancreatic drainage are caustic in nature, and cause skin breakdown. It can increase the risk of development of pressure ulcers. Saliva carries the lowest risk for skin breakdown. Bile and urine have a moderate risk of causing skin breakdown. 1,2
What is tissue ischemia?
If the pressure applied over capillary exceeds the normally capillary pressure and the vessel is occluded for prolonged period of time (reduced sensation and cannot responds to discomfort of ischemia, tissue death can result)
What characteristics differentiate a friction injury from a shear injury? Select all that apply. 1. Type of force 2. Location of the injury 3. Involvement of tissue 4. Condition of the client 5. Presentation of the injury
In a shear injury underlying muscle and tissue are involved, whereas in a friction injury the epidermis of the skin is affected. Shear injury presents as necrosis in the deep tissues with intact skin, while a friction injury presents as denuded epidermis and torn skin. Redness and pain is observed in affected areas. Shear force is a sliding movement of the skin and subcutaneous tissue while the underlying muscles and bones remain stationary. Frictional force is force between two surfaces moving against each other, such as skin and a bed sheet when the client is being transferred. Shear and friction injuries are not differentiated by the condition of the client or the location of the injury 1,3,5
While changing the position of a bedridden patient, the nurse observes a red-pink wound bed without slough, serosangineous-filled blisters, and partial loss of dermis thickness. What does the nurse infer from these findings? 1. The patient has a stage I pressure ulcer. 2. The patient has a stage II pressure ulcer. 3. The patient has a stage III pressure ulcer. 4. The patient has a stage IV pressure ulcer.
Irritation of the skin caused by frequent rubbing or pressing against the skin in a bedridden patient indicates a pressure ulcer. A stage II pressure ulcer is characterized by a red-pink wound bed without slough, serosangineous-filled blisters, and partial loss of dermis thickness. Discoloration of the skin, warmth, edema, hardness, pain, and intact skin with nonblanchable erythema are symptoms of a stage I pressure ulcer. Visible subcutaneous fat, presence of slough, and loss of full-thickness adipose tissue are symptoms of a stage III pressure ulcer. Presence of eschar, exposure of bone, tendon, or muscle, and full-thickness subcutaneous tissue loss are symptoms of a stage IV pressure ulcer. 2
What is a pressure ulcer?
Localized injury to the skin and other underlying tissue usually over a body prominence as a result of pressure or pressure in combination with shear and/or friction
The edges of a client's appendectomy incision are approximated, and no drainage is noted. Which type of healing should be applied? 1. Granulation 2. Primary intention 3. Tertiary intention 4. Secondary intention
Primary intention is the use of sutures or other wound closures to approximate the edges of an incision or a clean laceration. This reduces the risk of infection. Granulation tissue is formed to fill the gap between the edges of a wound and eventually fills in the surface of the wound. Healing by tertiary intention occurs with ulcers and wounds and results in scar formation. Secondary intention wound healing occurs slower than primary intention. 2
A long-term care facility encourage nurses to assess clients at risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. What tool is the facility using for risk assessment of pressure ulcer development? 1. GNASC tool 2.Braden Scale 3. Bates-Jensen tool 4. WOCN scale
The Braden Scale is a widely used tool for risk assessment of pressure ulcer development and is composed of six subscales, which are moisture, sensory perception, activity, mobility, nutrition, and friction or shear. The GNASC tool is used to assess stage I pressure ulcers in clients with dark skin tone. The Bates-Jensen tool is used to assess the wound status. WOCN or the Wound, Ostomy, and Continence Nurses Society does not provide any measurement or assessment tools. 2
What does the Braden Scale evaluate? 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the client at risk for skin breakdown 3. The amount of repositioning that the client can tolerate 4. The factors that place the client at risk for poor healing
The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds. 2
A nurse is attending to a client who is bedridden after a prolonged illness. The client has darkly pigmented skin, which makes it difficult for the nurse to detect pressure ulcers. What characteristics will alert the nurse about the possibility of developing pressure ulcers? Select all that apply. 1. The skin appears flabby. 2. Localized areas of skin may appear red. 3. The color remains unchanged when pressure is applied. 4. The circumscribed area of intact skin may be warm to touch. 5. Inflammation may be detected when compared with the surrounding skin.
The assessment for development of pressure ulcers in a client with dark skin may be difficult. If the skin color remains unchanged when pressure is applied, or the skin is warm to the touch, it indicates a potential for the development of pressure ulcers. These skin changes should be compared with the surrounding skin, looking for signs of inflammation. Intact, unaffected skin appears flabby, whereas skin areas that appear taut and shiny may have the potential to develop pressure ulcers. The affected area of skin may appear purple/blue or violet in dark-skinned clients instead of red. 3,4,5
What is the dermis and what does it to?
The inner layer of skin that provides strength, mechanical support and protection to underlying muscles, bones and organs
What is the epidermis and what does it consist of?
The top layer that has several layers (the thin outermost is the stratum corneum which consists of flattened, dead keratinized cells) (the inner layer is called the basal layer where cells divide proliferated & migrate to stratum corneum where they die)
The nurse understands that the nutritional status of a client is an important factor in wound healing. Which vitamins should be provided to the client to promote wound healing? Select all that apply. 1. Vitamin A 2. Vitamin B 3. Vitamin C 4. Vitamin D 5. Vitamin E
Vitamin A helps in epithelialization and closure of the wound. It helps in angiogenesis and promotes collagen formation. Vitamin C promotes collagen synthesis. It also enhances fibroblast function and immunological function. Vitamin B, Vitamin D, and Vitamin E do not have a role in wound healing. 1,3
A client with multiple fractures has casts that make it difficult to move voluntarily. A nurse notices red skin in the spinal area that blanches on applying pressure. What measures does the nurse take to decrease the risk of development of pressure ulcers in this client? Select all that apply. 1. Position the client in the most comfortable position and do not move. 2. Cover the hyperemic skin area with a sterile dressing and apply antiseptics. 3 . Check the skin around the casts regularly for any signs of impaired skin integrity. 4 . Take care to avoid friction injuries during repositioning, bathing, or transferring of the client. 5. Use good hygiene techniques to ensure the client's skin is clean and dry after bowel mo
When a nurse suspects a developing pressure ulcer, other areas should be checked for impaired skin integrity, especially around casts. It helps in early detection and prompt treatment. The nurse should ensure that the skin of the client is clean and dry and not overly moistened for prolonged periods of time. Excess moisture increases the risk of pressure ulcers. When repositioning, bathing, or transferring the client, care should be taken to avoid friction injuries to the affected area or other areas. The client should be repositioned at regular intervals to relieve pressure and avoid pressure being exerted on one or the same body parts constantly. The area of hyperemic skin should not be covered, but inspected at regular intervals for abnormal hyperemia, induration, or non blanching. 3, 4, 5
A nurse is caring for older adult clients in a nursing home. The nurse understands that older adults are susceptible to development of pressure ulcers and other wounds. What makes older adults more vulnerable to developing pressure ulcers? Select all that apply. 1. Increased skin elasticity 2. Increased inflammatory response 3. Increase of the hypodermis in size with age 4. Diminished inflammatory response 5. Loss of collagen and thinning of muscles
With age the skin loses elasticity, has decreased collagen, and the underlying muscles thin out, causing the skin to be easily torn with shearing and friction trauma. This leads to development of pressure ulcers. The decreased inflammatory response in older adults results in poor healing processes due to slow epithelialization. In old age the hypodermis decreases in size and there is little padding in the skin over bony prominences, causing easy skin breakdown. 4, 5
