Skin and Tissue Integrity – Taylor Chapter 33

Question-and-answer flashcards covering layers of skin, wound classification, healing phases, factors affecting healing, pressure injury prevention and staging, Braden scale, nursing assessments, interventions, and complications.

What are the three primary layers of the skin?

Epidermis, dermis, and hypodermis (subcutaneous fascia).

Which epidermal sub-layer is composed of dead cells that continually slough off?

The stratum corneum.

Why does the epidermis not bleed when superficially scratched?

It is avascular (contains no blood vessels).

List three developmental or intrinsic factors that can affect skin integrity.

Developmental level, aging, and comorbid conditions.

Give two environmental/extrinsic factors that negatively influence skin integrity.

Moisture (maceration) and pressure/shear.

Define a papule and provide an example.

Solid elevation < 0.5 cm; example: allergic eczema.

Define a vesicle and provide an example.

Small fluid-filled blister within or under the epidermis; example: herpesvirus infection.

Define an ulcer in dermatology terms.

Area of destruction of the entire epidermis, e.g., a pressure sore.

Which wound healing intention involves clean, straight incisions closed with sutures?

Primary intention healing.

Name the three classic phases of wound healing in order.

Inflammatory, proliferative, maturation.

What type of healing occurs when a wound is left open, fills with granulation tissue, and closes slowly?

Secondary intention.

State two local factors that can delay wound healing.

Pressure on the wound and infection.

Name two systemic factors that slow wound healing.

Poor circulation/oxygenation and inadequate nutritional status.

Identify four common complications of wound healing.

Hemorrhage, infection, dehiscence, evisceration, and fistula formation (any four).

What is the difference between dehiscence and evisceration?

Dehiscence is separation of wound edges; evisceration is protrusion of internal organs through the dehisced wound.

Define a pressure injury.

Localized damage to skin and/or underlying tissue, usually over a bony prominence, as a result of prolonged pressure or pressure in combination with shear.

List the six recognized categories of pressure injuries.

Suspected deep tissue injury, Stage 1, Stage 2, Stage 3, Stage 4, and unstageable.

Describe a Stage 1 pressure injury.

Intact skin with non-blanchable redness over a localized area, usually a bony prominence.

Which stage of pressure injury involves full-thickness tissue loss with exposed bone, tendon, or muscle?

Stage 4.

Name the six subscales of the Braden Pressure Ulcer Risk Assessment tool.

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

On the Braden scale, a lower total score indicates what?

Higher risk for pressure injury development.

Give two examples of nursing assessment parameters for skin.

Temperature, texture, moisture, turgor, vascularity, tone, scars, or lesions (any two).

What does the ‘C’ stand for in the ABCDEF rule for assessing skin lesions?

Color.

According to the ABCDEF mnemonic, when is a mole’s diameter concerning?

When it is greater than 6 mm (about the size of a pencil eraser).

List three key elements of a thorough wound assessment.

Location, size (including depth), drainage amount/type, tunneling, wound edges, wound bed characteristics, and patient response (any three).

Name two psychosocial effects that wounds can have on patients.

Pain, anxiety/fear, altered activities of daily living, or changes in body image (any two).

Why is regular turning and positioning crucial in pressure injury prevention?

It relieves pressure, promotes circulation, and reduces shear on bony prominences.

Identify three common patient positions used in nursing care.

Prone, supine, semi-Fowler’s, high Fowler’s, lateral recumbent, Trendelenburg, reverse Trendelenburg, Sims, jackknife, or lithotomy (any three).

What are two skin hygiene interventions to help maintain skin integrity?

Gentle cleansing/moisturizing and prompt continence care to prevent maceration.

List three components of wound management interventions.

Cleansing/irrigation, debridement, appropriate dressings, drains, negative-pressure therapy, sutures/staples, bandages/binders, heat or cold therapy (any three).

During a sterile dressing change, why is wound irrigation performed before applying a new dressing?

To remove debris, reduce bacterial load, and promote optimal healing conditions.

Explain the purpose of negative-pressure wound therapy.

Applies controlled suction to remove exudate, reduce edema, promote perfusion, and stimulate granulation tissue formation.

Which local condition—desiccation or maceration—results from excessive dryness, and how does it affect healing?

Desiccation; it impedes epithelialization and slows wound healing.

How does protein deficiency affect wound healing?

Reduces collagen synthesis, delays granulation tissue formation, and weakens wound tensile strength.

What is the recommended nursing response when a patient’s abdominal incision suddenly dehisces and viscera protrude?

Cover with sterile saline-soaked gauze, place patient in low-Fowler’s with knees bent, call the surgeon immediately, and prepare for surgery.

State one reason elderly patients are at higher risk for skin tears and pressure injuries.

Thinner epidermis/dermis, decreased subcutaneous fat, decreased collagen, or impaired perfusion.

Why is adequate oxygenation essential for wound healing?

Oxygen is required for collagen synthesis, leukocyte function, and angiogenesis in the healing tissue.

What dressing type is often chosen for heavily exudative wounds to absorb drainage?

Alginate or foam dressings.

When assessing friction and shear risk, what patient behavior is most concerning?

Sliding down in bed or chair frequently.

Which mattress type is recommended for a Braden score indicating high risk (≤12)?

Dynamic air mattress (low-air-loss or alternating-pressure surface).

Before applying heat or cold therapy, what key assessment must the nurse perform?

Check the patient’s skin integrity, circulation, sensory perception, and overall tolerance.