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 ______ is caused by ____

dehydration; 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

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?

a 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 based on which factor?

Depth of the wound and extent of 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.

What is the primary goal of positive-pressure wound therapy?

To deliver oxygen or medications directly into the wound bed

What is the main therapeutic effect of negative-pressure wound therapy?

Stimulating granulation tissue formation and removing excess exudate

How are pressure injuries in stages 1 through 4 classified?

By the depth and extent of tissue involvement

What is the primary purpose of using binders or bandages in wound care?

To support and immobilize the wound, reducing stress on healing tissues

Which method of wound debridement uses physical forces such as wet-to-dry dressings or irrigation?

mechanical

Which type of debridement involves the application of topical agents to break down necrotic tissue?

Enzymatic

Which debridement process uses the body’s own enzymes and moisture-retentive dressings to rehydrate and soften necrotic tissue?

Autolysis

Which debridement technique involves the direct removal of necrotic tissue with a scalpel, scissors, or other sharp instrument?

Sharp

What is the greatest concern when a patient develops hemorrhage at a wound site?

Loss of fluid volume leading to hypovolemic shock

Which sign most strongly indicates wound infection?

Purulent drainage with redness and swelling

What is a fistula in wound healing?

An abnormal passage connecting two body cavities or a cavity to the skin

Which type of wound drainage is described as bright red and indicates active bleeding?

Sanguineous

What type of wound drainage appears as a mix of bloody fluid and straw-colored serum?

Serosanguineous

Which wound drainage is thick, yellow, or green and contains pus, often indicating infection?

Purulent

Which type of healing occurs in superficial wounds limited to the epidermis and results in no scar formation?

Regeneration

A clean surgical incision with well-approximated edges heals by which type of wound healing, usually leaving minimal scarring?

Primary intention

How are wounds classified when based on the depth of tissue involvement?

As superficial, partial-thickness, or full-thickness

Which type of wound classification refers to an injury in which an object enters the skin and underlying tissues, sometimes creating a tunnel?

Penetrating

A client is being assessed for risk of impaired skin integrity. The factor that places them at the greatest risk is:

Decreased sensation

Which would put a client at greatest risk for impaired skin integrity?

Decreased sensation