©PREP4EXAMS @2024 [REAL EXAM DUMPS] Wednesday, July 17, 2024 1:27 AM
Skin Integrity and Wound Care Exam Prep
Questions and Answers (100% Pass)
What are the three layers of the skin? - ✔️✔️epidermis, dermis, subcutaneous tissue
What are the functions of the skin? - ✔️✔️protection, temperature regulation, psychosocial,
sensation, vitamin D production, immunological, absorption, elimination
How does skin protect? - ✔️✔️acts as a barrier, prevents infection and injury, loss of moisture;
first line of defense; any breech decreases protection
What affects skin integrity? - ✔️✔️developmental level, circulation, mobility, state of health,
medical interventions
What are the developmental factors in infants? - ✔️✔️skin is thinner, weaker, more susceptible
to infection
What are developmental factors in older adults? - ✔️✔️thinner, dryer skin; delayed healing
time, less elastic
How does circulation affect skin integrity? - ✔️✔️promotes long skin cell life; immobility
decreases circulation to tissues; decreased circulation leads to inadequate cell nutrition
How does state of health affect skin integrity? - ✔️✔️Physical stature: very thin and obese;
reduced sensation: temp, pressure, friction; dehydration/malnutrition: adequately
nourished/hydrated skin cells are more resistant to injury; diseases: decreased
sensation/increased risk of skin complication; mental status: may affect sensation, ability
understand instructions; skin moisture: diaphoresis, incontinence
What are the types of wounds? - ✔️✔️Intentional, unintentional, open, closed, acute, chronic
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, ©PREP4EXAMS @2024 [REAL EXAM DUMPS] Wednesday, July 17, 2024 1:27 AM
What are the phases of wound healing? - ✔️✔️hemostasis, inflammatory phase, proliferation
phase, maturation phase
Describe hemostasis - ✔️✔️occurs immediately after tissue injury; blood vessels constrict,
clotting begins; capillary permeability increases; exudate causes swelling/pain; increased
perfusion causes redness and heat
Describe the inflammatory phase - ✔️✔️4-6 days, phagocytosis of bacteria and cellular debris;
macrophages release growth factors for new cells
Describe the proliferation phase - ✔️✔️fibroblastic, regenerative, connective tissue phase;
several weeks; synthesize collagen and produce growth factors to form blood vessels and
endothelial cells; capillaries grow across wound; granulation tissues
Describe the maturation phase - ✔️✔️~day 21; collagen is remodeled to make wound stronger,
new collagen deposited, compresses blood vessels
What are the types of wound healing? - ✔️✔️primary intention (well approximated edges),
secondary intention (poorly approximated edges, granulation tissue formation) tertiary
intention (delayed primary intention)
What factors affect would healing? - ✔️✔️pressure, desiccation, maceration, trauma, edema,
infection, necrosis, age, circulation/oxygenation, nutritional status, wound condition,
meds/health status
What are some nursing interventions to facilitate wound healing? - ✔️✔️adequate blood
supply, good nutrition, rest, stress reduction, prevent infection
What are some would complications? - ✔️✔️infection, hemorrhage, dehiscence and
evisceration, fistula formation
Describe infection - ✔️✔️bacteria ever wound; can be hospital acquired; S/S usually occur
w/in 2-7 days; lead to osteomyelitis or sepsis
Describe hemorrhage - ✔️✔️bleeding; can be external or internal (hematoma); check fresh
wound for frequent bleeding; change or reinforce dressing as needed; monitor vital signs
Describe dehiscence - ✔️✔️partial or total separation of wound layers due to excessive stress
on wounds that are not healed
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