NR 224 Final Exam 2 Study Guide Chapter 48: SKIN INTEGRITY AND WOUND CARE
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Course
NR 224
Institution
NR 224
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 epidermi...
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.
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