NCLEX STYLE: Chapter 32: Skin Integrity & Wound Healing

What layer of the skin contains the stratum corneum and stratum germinativum?

Epidermis

What layer of the skin contains connective tissue, hair follicles, and glands?

Dermis

What changes occur in older adult skin that make it prone to injury?

Less elasticity, dryness, reduced collagen

Increased pressure, shearing, and friction from immobility can lead to what?

Skin breakdown

Which nutrient is essential for collagen formation?

Vitamin C, zinc, copper

Poor skin turgor from dehydration is most directly caused by lack of what?

Water

Diminished sensation increases risk for what problem?

Pressure injury and breakdown

Impaired circulation negatively affects what process in the skin?

Tissue metabolism

What side effect of medications can increase risk of impaired skin integrity?

Itching and rashes

Prolonged moisture exposure leads to what?

Maceration

How does fever affect skin integrity?

Depletes moisture & ↑ metabolic rate

Infections impede wound healing by doing what?

Competing for oxygen/nutrients

A clean surgical incision with approximated edges heals by what process?

Primary intention

A wound with tissue loss that heals from inner layer to surface heals by what process?

Secondary intention

Granulating tissue brought together with delayed closure describes what type of healing?

Tertiary intention

What are the three phases of wound healing?

Inflammatory, proliferative, maturation

What type of drainage is straw-colored?

Serous exudate

Drainage that is a mixture of bloody and straw-colored fluid is called what?

Serosanguineous

Yellow drainage containing pus is called what?

Purulent exudate

What wound complication involves partial or total separation of wound layers?

Dehiscence

What is it called when abdominal organs protrude through a wound?

Evisceration

A nurse assessing pressure injury risk uses which tool that includes moisture, activity, mobility, and nutrition?

Braden Scale

A Braden Scale score less than what indicates risk for pressure injury?

18

The Norton Scale evaluates what factors?

Physical condition, mental state, activity, mobility, incontinence

What type of debridement uses the body’s own enzymes and moisture?

Autolysis

What wound care intervention applies suction to promote healing?

Negative pressure wound therapy

What percentage of hospitalized clients are affected by pressure injuries?

15%

What causes a pressure injury?

Unrelieved pressure → ischemia

Which are intrinsic risk factors for pressure injuries?

immobility, poor nutrition, dehydration, etc

Which are extrinsic risk factors for pressure injuries?

friction, pressure, shearing, moisture

Stages 3 and 4 pressure injuries involve what?

Tissue necrosis

What tool is used to monitor healing progress of pressure injuries?

PUSH Tool

What nursing intervention is key for pressure injury prevention?

Frequent repositioning, moisture control, nutrition