Skin Structure and Wound Healing, Exams of Nursing

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WOUND CARE EXAM 1 EXAM TEST 2024. WOUND CARE EXAM 1 EXAM TEST 2024.2025 WITH GUARANTEED ACCURATE ANSWERS Skin Facts - ACCURATE ANSWERS✔✔ -Size: 2 square meters -Weight: 15% TBW -Recieves 1/3 of total circulation. -Largest Organ Skin Functions - ACCURATE ANSWERS✔✔ -Thermoregulation -Protection -Immunity -Sensation -Metabolism

-Communication Epidermal Appendages (Skin) - ACCURATE ANSWERS✔✔ -Nails -Hair Follicles -Sweat glands Epidermis (Layers--superficial to deep) - ACCURATE ANSWERS✔✔ - Stratum corneum -stratum lucidum -stratum granulosum stratum spinosum -stratum basle Epidermis - ACCURATE ANSWERS✔✔ -Outermost layer -uniform thickness (except palms/soles = 0.06-0.6 mm) -Stratified squamos epithelial cells ( 20 cells thick; Very young/old have only 12)--> leads to more wounds -5 Layers Stratum Corneum - ACCURATE ANSWERS✔✔ -Top horny Layer -cells elongate -dead keratinized cells -sloughs off and is replaced by cells below

Stratum Lucidum - ACCURATE ANSWERS✔✔ -Few Layers of dead keratinocytes Stratum Granulosum - ACCURATE ANSWERS✔✔ -3-5 layers of cells -Diamond Shaped Cells Stratum Spinosum - ACCURATE ANSWERS✔✔ -Prickly Layer -Cells have active nuclei Stratum Basale - ACCURATE ANSWERS✔✔ -AKA- Basal Layer (Stratum Germinativum) -Attached to dermis by basement membrane -Takes 2-4 weeks to migrate upward -Melanocytes Basement Membrane - ACCURATE ANSWERS✔✔ -Separates epidermis from dermis -Rete pegs - point up -Rete ridges - point down -Ancer epidermis to dermis -Flattens with age (leads to ski tears) Langerhans Cells - ACCURATE ANSWERS✔✔ -Produced in bone marrow

-migrate to epidermis -Fight bacteria and viral fungal infection -Decrease with Age and UV exposure --> decrease immune function Papillary Dermis - ACCURATE ANSWERS✔✔ -Layer just below the basement membrane -Elastic Fibers -Papillary loops provide nutrients to dermis Reticular Dermis - ACCURATE ANSWERS✔✔ -Forms base of dermis -Thick collagen fibers -Cutaneous blood vessels Important Dermal Cells - ACCURATE ANSWERS✔✔ -Fibroblasts -Macrophages -Mast Cells -Nerve Cells -Epidermal Appendages Fibroblasts (dermal cells) - ACCURATE ANSWERS✔✔ -produce collage and elastin -important for elasticity in would healing

Macrophages and WBC (dermal cells) - ACCURATE ANSWERS✔✔ - Regulate Wound Repair process (fight infection) -Phagocytize bacteria -break down damage tissue -synthesize collagenase and elastase (enzymes that break down dead tissue) Mast Cells (dermal cells) - ACCURATE ANSWERS✔✔ -produce histamine -->causes vasodialation -Activate inflammatory response Hypodermis - ACCURATE ANSWERS✔✔ -A subcutaneous layer of loose connective tissue containing a varying number of fat cells: -Adipose Tissue -Fascia -Lymphatic Vessels Adipose Tissue - ACCURATE ANSWERS✔✔ -Loose connective tissue -holds fat -Energy reserve, protection, thermoregulation Fascia - ACCURATE ANSWERS✔✔ -Fibrous connective tissue -surrounds, separates, facilitates movement

Lymphatic Vessels - ACCURATE ANSWERS✔✔ -A vessel that conveys lymph. Age Related Changes - ACCURATE ANSWERS✔✔ -NEONATAL (term delivery + 2 weeks) -Very permeable -caution with topical meds -Infants (After 42 weeks) -Skin, tears, occipital skin breakdown Partial Thickness - ACCURATE ANSWERS✔✔ -confined to epidermis and superficial (papillary) dermis Full Thickenss - ACCURATE ANSWERS✔✔ -Total loss of skin layers and often include deeper tissues (may see bone) Acute Wound - ACCURATE ANSWERS✔✔ -Occurs suddenly, predictable repair process, durable closure Chronic Wound - ACCURATE ANSWERS✔✔ -Unpredictable repair process -Often caused by chronic inflammation or circulatory compromise

Acute Wound Healing (3 Phases) - ACCURATE ANSWERS✔✔ 1- Inflammation (vascular response, cellular response) 2-Proliferation 3-Maturation and remodeling Inflammation - ACCURATE ANSWERS✔✔ -Produces erythema, edema, exudate -Lasts 1-3 days -Vasodilation lets plasma and blood cells leak into wound -Neutrophils target bacteria and release growth hormones -Growth factors attract more leukocytes 4 signs of inflammation - ACCURATE ANSWERS✔✔ -Red -Hot -Swollen -Tender Exudate - ACCURATE ANSWERS✔✔ -Creamy yellow fluid -contatins fluid, proteins, WBCs PMNs (Polymorphonuclear Neutrophils) - ACCURATE ANSWERS✔✔ -Circulating WBCs -Migrate to injury site -Excellent Scavengers

-Secrete Enzymes that break down injured tissue **Keep tissue MOIST for healing Proliferation (4 events) - ACCURATE ANSWERS✔✔ -Angiogenesis -Granulation tissue formation -wound contraction / collagen synthesis **occurs best with moist wound bed Angiogenesis - ACCURATE ANSWERS✔✔ -formation of new blood vessels -complex process -inflammatory cells secrete angiogenic substances -endothelial cells adjacent to wound create pathways for new vessels -New endothelial cells project "sprouts" into wound bed --develop capillary tubes. **Does not heal linearly (equally) Granulation Tissue - ACCURATE ANSWERS✔✔ -Composed of capillary loops and extracellular matrix (new connective tissue) -Contains fibroblasts and inflammatory cells -Fibroblasts are the ONLY cells that make collage ***

-Beefy red color Never do we to dry dressing Wound Contraction - ACCURATE ANSWERS✔✔ -Myofibroblasts pull wound edges together -speed varies with size and shape of wound -Epithelialization Epithelialization - ACCURATE ANSWERS✔✔ -Epithelial cells migrate across wound bed -Need to keep wound edges open -If dry, epethelial cells stop or move to moisture Wound Maturation - ACCURATE ANSWERS✔✔ -When epithelial cells "meet in middle" they stop moving laterally -Begin growing upward like normal dermal cells -Collagen fibers mature -Can force collagen fibers to realign (Tension Theory) -Scar Tissue = 80% of original tissue strength Wound Closure by Primary Intention - ACCURATE ANSWERS✔✔ - Surgery and minor cuts -wound clean so shorter inflammatory phase

-Epithelialization begins within 24 hrs -"Healing Ridge" should be palpable by 5-9 days post-op Secondary Intention - ACCURATE ANSWERS✔✔ -When wound edges cant be approximated -Heals by granulation -No homeostasis, so longer process -No release of growth factors by clot breakdown -Surgical debridement can jump start healing Tertiary Intention - ACCURATE ANSWERS✔✔ -AKA delayed primary close -Delay of closure due to: Infection, Patient too ill/unstable Abnormal Inflammation - ACCURATE ANSWERS✔✔ -Absence Inflammation -Prolonged Inflamation Absence Information - ACCURATE ANSWERS✔✔ -wound lacks signs of inflammation (due to steroids or disease compromised) Prolonged Inflammation - ACCURATE ANSWERS✔✔ -R/T foreign body in wound -Heavy bioburden

-Ischemic wound bed -necrotic tissue in wound -Harsh dressing change techniques Hypogranulation - ACCURATE ANSWERS✔✔ -failure to build granulation matrix -Low levels of growth factors -High levels of preteases breakdown growth factors Hypergranulation - ACCURATE ANSWERS✔✔ -Granulation tissue stacks up "proud flesh" -Prevents epithelialization -Must keep wound edges open Hypertrophic Scarring/Keloid - ACCURATE ANSWERS✔✔ -Raised, Red, and Pruritic -Composed of connective tissue Both More common in: Dark skinned people, under age 30, with family history. Hypertrophic - ACCURATE ANSWERS✔✔ -doesnt extend beyond original wound -common over joints

-may regress spontaneously Keloid - ACCURATE ANSWERS✔✔ -Extends beyond original wound -Common on trunk, delotoid, earlobes -Doesn't shorten/cause contractures **doesnt affect ROM of Joints Contractures - ACCURATE ANSWERS✔✔ -Shortening of scars ie: burns -more problematic over joints -PREVENTION IS CRUCIAL Dehiscene - ACCURATE ANSWERS✔✔ -Seperation of wound edges -Factors Affecting Wound Healing - ACCURATE ANSWERS✔✔ - Wound Characteristics -Local Factors -Systematic Factors Wound Characteristics - ACCURATE ANSWERS✔✔ -Onset: Rapid or Insidous -Duration: longer its there harder to heal -Location: Related to motion, blood supply, and pressure

-Size: bigger they are the slower they heal -Temperature: Faster healing with normal temperature -Hydration: MOIST WOUND BED is critical to healing -Necrotic Tissue: must be removed -Infection- prolongs inflammation and delays healing Local Factors - ACCURATE ANSWERS✔✔ -Oxygenation: requires circulation -Inflammation and proliferation phases require most O -Fibroblasts need O -may need vascular consult -Sensation: -Peripheral neuropathy a problem -So patient identifies and protects wound -Mechanical Stress: -Friction -Shear (internal against internal) -Tension on wound edges -edema Systematic Factors (Age) - ACCURATE ANSWERS✔✔ -Delayed in elderly

-Decreased collagen synthesis -Decreased inflammatory response -Decreased blood supply to skin Systematic Factors (Nutrtion) - ACCURATE ANSWERS✔✔ -Protein -Carbs -Fats -Ascrobic Acid -Iron -Zinc Systematic Factors (Comorbidities) - ACCURATE ANSWERS✔✔ - Diabetes mellitus -Blood sugar >180 makes WBCs ineffective -compromises fibroblast activity -reduces growth factors and impairs collagen sythesis -should be 70- -Chronic Lung Disease -Imapairs oxygenation -Discourage smoking Systematic Factors (Depressed Immune Function) - ACCURATE ANSWERS✔✔ -HIV/AIDS

-Corticosteroids -Dose of 40mg/day affects angogenesis, inflammation, contraction epithelialziation. (20-40 has modest effect -Topical Vitamin A enhances macrophage migration -NSAIDs in normal dose dont affect wound healing Nutrition and Wound Healing - ACCURATE ANSWERS✔✔ - Uncomplicated wound may heal without paying attention to nutrition -Patients with chronic wounds MUST have nutrition examined Essential Components - ACCURATE ANSWERS✔✔ -Water -Protein -CHO -FATS Water - ACCURATE ANSWERS✔✔ -Essential for all cellular functions, INCLUDING repair! -Need 30-35 ml/kg body wt per day -(220 lb person = 100 kg x 30 ml =3000 ml) -Burns and open wounds dramatically incr fluid loss due to evaporation. -May need 40-60 ml/kg/day Water (Cont.) - ACCURATE ANSWERS✔✔ -Need assessment of fluids -1 Lt = 2.2 lbs

-Rapid weight loss/gain = Fluid -Check pt's I and O records -Options for repacement? -PO, IV, Enteral tube -Barriers: Unconscious, need greater than person can tolerate, cancer, stroke Protein - ACCURATE ANSWERS✔✔ -Require collagen synthesis and immune function -can be lost in wound drainage -Low = alters osmotic pressure (incr interstial fluid, O2 can diffuse through fluid well) -Edema can put pressure on blood vessels and restrict blood flow Carbohydrates - ACCURATE ANSWERS✔✔ -Provide energy for tissue maintenance and repair -Can help prevent use of protein stores for energy (protein sparing) -Glucose essential for phagocytosis Fats - ACCURATE ANSWERS✔✔ -Energy source (protein sparing) -Essential for adequate fat-soluable vitamins -helps with thermoregulation/insulation

-essential for healthy cell membranes Additional Nutrients Needed - ACCURATE ANSWERS✔✔ -Vitamis: A, C, K, B complex, E -Minerals: zinc, iron, copper, Mg, Ca, Phosphorus Vitamin A - ACCURATE ANSWERS✔✔ -Maintains skin and epithelial tissue -Helps with collagen sythesis, granulation, epithelialization -Others: -Increase tensile strength of wound tissue -reduce wound healing problems when patient on steroids -enhance wound healing in diabetic Vitamin C - ACCURATE ANSWERS✔✔ -Essential to build and maintain tissue -Facilitates iron absorption -Essential for collagen synthesis others: -Activates WBCs -Enhance WBCs ability to migrate to wound -Limit damaging effect of free radicals

Vitamin K - ACCURATE ANSWERS✔✔ -Essential for blood clotting Vitamin B Complex - ACCURATE ANSWERS✔✔ -essential for normal immune function and energy metabolism Vitamin E - ACCURATE ANSWERS✔✔ -Decreases inflammatory phase of wound healing -Decreases platelet adhesion Zinc - ACCURATE ANSWERS✔✔ -Critical for normal wound repair (too much may impair copper function) -Collagen and protein synthesis -Immune function -Supplementation should be considered if level low or chronically poorly nourished Iron - ACCURATE ANSWERS✔✔ -Collagen synthesis and formation of hemoglobin -Assists with immune function Copper - ACCURATE ANSWERS✔✔ -Hgb synthesis -Iron absorption

Magnesium - ACCURATE ANSWERS✔✔ -Deficiency can increase risk of hypertension and vasoconstriction Calcium - ACCURATE ANSWERS✔✔ -fibrin synthesis, blood clotting Phosphorus - ACCURATE ANSWERS✔✔ -Variety of enzyme systems Nutritional Assessment - ACCURATE ANSWERS✔✔ -Height -Weight (current and usual) -Skin fold measurements Compare usual/current weight: (Actual/Usual) x 100% = % of usual weight Ways to define Significant weight loss - ACCURATE ANSWERS✔✔ - Unplanned loss > 10% in 6 months = catabolic state -1-2% of body weight/week -5% per month (may incr risk of death) -10% in 6 months -In Long Term Care (LTC) unplanned weight loss is significant -If unplanned weight loss Refer pt to MD

Laboratory Data - ACCURATE ANSWERS✔✔ -Serum protein levels -- albumin, prealbumin, transferrin -shorter half life = more sensitive changes -albumin (3.5 - 5.0 g/dL) - half life 21 days (affected by hydration) -prealumin (16 - 30) - half life 3-4 days (not affected by hydration) -Blood sugar(70-99) - Increased risk of ulceration and delayed healing Caloric Need - ACCURATE ANSWERS✔✔ -Convert wt to kg -Multiply wt x 30-35 (varies due to age and activity level) -Gives you caloric intake for wound healing. **this is shortcut should refer to RD **NOT all calories are created equal! Nutritional Needs (protein) - ACCURATE ANSWERS✔✔ -convert lbs to kg -multiply weight by 1.2 - 1. -1.5 preferable but MUST confirm adequate fluid needs met and renal function. Nutritional Needs (Fluid) - ACCURATE ANSWERS✔✔ - kg x 30 -need more fluid if larger losses (fever, large draining wound, vomiting, diarrhea)

Clinical Observations - ACCURATE ANSWERS✔✔ -Muscle Wasting -Dry thin hair -Dry Flaky Skin -Dry Mucous Membranes -Delayed wound healing Supplements - ACCURATE ANSWERS✔✔ -Most clinician recommend Multi vit (2011 contradicts this) -Vitamin C 500-2000 mg/day (only for heavily draining wounds) -Zinc replacement controversial -excess = upset GI -if defecit give 220 daily for 1-2 weeks or until normal level -found in meat, milk, eggs -Oxandrin (oxandrolone)- anabolic steroid -if pt lost > 10% LBM -many contraindications so be cautious Other options for Oral Intake - ACCURATE ANSWERS✔✔ - Nutritional supplements taken orally -Boost, Ensure, Carantion complete -High calorie, nutrient dense snack

Obese Patients - ACCURATE ANSWERS✔✔ - 2/3 of US adults obese or overweight -consider risk vs. benefits of weight loss if pt has wound -NO evidence guidelines for nutritional needs of obese pt with pressure ulcer -Require adequate calories, protein, fluids, nutrients -Goal is to promote healing -Monitor overall skin integrity Calculation of Nutritional Needs for Obese Patients - ACCURATE ANSWERS✔✔ -Limited research for guidelines -Protein needs vary: -Renal status -presence of ulcer or wound -hepatic disease -Fluid; 1mL/calorie consumed or 30 mL/Kg BW Tube Feeding - ACCURATE ANSWERS✔✔ -If nutritional gap is large -Must have normal GI tract function -Can be nasal tube or stomach -consult with nurses or clinical dieticians to monitor progress Enteral Feeding Tube Sites - ACCURATE ANSWERS✔✔ -Nasograstric tube

-Nasoduodenal tube -Gastrostomy tube -Jejunostomy tube -Nasojejunal tube Intravenous - ACCURATE ANSWERS✔✔ -Last Resort (expensive, increased risk of complications) -Total parenteral nutrition (TPN) -Increased risk of infection at IV site -Blood sugar control issues Nutritional Bottom Line!! - ACCURATE ANSWERS✔✔ -Wounds cant heal without nutrtional building blocks no matter how good your dressing! Value of Examination - ACCURATE ANSWERS✔✔ -Guides: -making diagnosis -selecting effective interventions -Optimizes pt care and reduces HC Costs -Reassures clinician and pt treatments working (incr pt compliance) Examination - ACCURATE ANSWERS✔✔ -methodologies in wound examination must be consistent

-data must be objective, precise, reproducible to draw conclusions -interpretation should be objective (EVIDENCE BASED) -not subjective Wound Examination Guide - ACCURATE ANSWERS✔✔ -History -System Review -Test and Measures (wound characteristics; condition of surrounding skin) -Pt Diagnosis -Prognosis -Intervention -Outcomes History - ACCURATE ANSWERS✔✔ -Demographics -Social History -Living Enviroment -Functional Status/Activity Level -Health Behaviors -Medical and Surgical History -Family History -Medications -Allergies (latex sulfa, adhesives) -Clinical Tests

History cont. - ACCURATE ANSWERS✔✔ -Current wound event (when/how, pain level, does pain change, progress) -Previous wounds (when/how, prior treatment, prior diagnostic tests/results) System Review (Cardiopulmonary) - ACCURATE ANSWERS✔✔ -HR -BP -RR -Edema -Peripheral pulses -pulse oximetry Systems Review (Musculoskeletal) - ACCURATE ANSWERS✔✔ - posture -ROM -Strength Systems Review (Neuromuscular) - ACCURATE ANSWERS✔✔ - Mobility and gait System Review (Gastrointestinal and Urogenital) - ACCURATE ANSWERS✔✔ -Nutrition -Incontinece -Signs of DM or UTI