Chapter 32: Skin Integrity & Wound Healing

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

The Epidermis.

Which skin layer contains connective tissue, blood vessels, and nerves?

The Dermis.

Older adult skin is characterized by:

Less elastic, drier, reduced collagen.

Which factor contributes to skin breakdown related to immobility?

Shearing, friction, and pressure.

Which nutrient is most important for collagen formation?

Vitamin C, zinc, and copper.

Poor skin turgor related to dehydration is caused by:

Fluid loss.

Diminished sensation increases risk for skin breakdown because:

Patients may not notice pressure or injury.

Impaired circulation affects wound healing by:

Reducing tissue metabolism.

Which medication side effect can impair skin integrity?

Rashes and itching.

Prolonged moisture on the skin leads to:

Maceration.

Fever increases risk for impaired skin integrity because it:

Increases metabolic rate and depletes moisture.

Which lifestyle factor negatively affects skin integrity?

Tattoos and piercings.

A wound with tissue loss that heals from the inside outward is classified as:

Secondary intention.

Which wound healing process involves delayed closure after granulation tissue forms?

Tertiary intention.

Which phase of wound healing includes clotting and inflammation?

Inflammatory.

In which phase of wound healing does collagen and granulation tissue form?

Proliferative.

Which type of wound drainage is straw-colored?

Serous.

Which type of exudate contains both blood and pus?

Purosanguineous.

Which complication of wound healing is defined as wound edges separating?

Dehiscence.

Which complication of wound healing occurs when internal organs protrude through the wound?

Evisceration.

The Braden scale evaluates which factors?

Sensory perception, moisture, activity, mobility, nutrition, friction/shear.

A Braden scale score of 15 indicates:

Moderate risk.

Which scale assesses physical condition, mental state, mobility, and incontinence?

Norton scale.

Which lab test helps identify wound infection?

Wound culture.

Which wound debridement uses maggots to remove dead tissue?

Biotherapy.

Which wound therapy applies suction to promote healing?

Negative pressure wound therapy.

Which dressing type provides a moist environment and is often used for partial-thickness wounds?

Hydrocolloid.

Which condition results from unrelieved pressure leading to ischemia?

Pressure injury.

Which intrinsic factor increases risk for pressure injury?

Immobility.

Which extrinsic factor increases risk for pressure injury?

Friction.

Pressure injuries are staged primarily by:

Depth and tissue involvement.

Which stages of pressure injury involve tissue necrosis?

Stages 3 and 4.

Which tool is used to monitor pressure injury healing over time?

PUSH tool.

Which prevention measure reduces pressure injury risk?

Meticulous skin care and moisture control.

An elderly patient who has lost weight, has impaired sensation, and is incontinent is at high risk for:

Pressure injury development.