NURSING
Fundamentals II Exam 1
Chapter 29 – Wound Care (clean wounds)
1. Describe the normal structure and function of the skin
a. Epidermis
i. Regenerate 4-6 weeks
ii. Divided into more layers – corneum, lucidum, granulosum, spinosum, basale
b. Dermis
c. Subcutaneous layer
i. Layer of adipose tissue
ii. Delivers the blood supply to the dermis
iii. Provides insulation and has a cushioning effect
d. Factors affecting skin integrity
i. Wounds – disruptions in skin integrity
ii. Aging process
e. Need-to-know key terms
i. Dehiscence
1. Occurs when a wound fails to heal properly, and the layers of the skin
and tissue separate
a. Ex: Compliant by patient that something has given away can be
seen in a postoperative patient
2. It involves abdominal surgical wounds and occurs after a sudden strain,
such as coughing, vomiting, or sitting up in bed
ii. Evisceration
1. Seen when vital organs protrude through a wound opening
iii. Granulation
1. Red, moist tissue composed of new blood vessels, the presence of which
indicates progression toward healing
iv. Serous
1. Clear, watery fluid from plasma
v. Serosanguineous
1. Pink to pale and contains a mixture of serous and red, bloody fluid
vi. Sanguineous
1. Usually indicated bleeding and is bright red
vii. Purulent
1. Indicative of an infection and will need to be resolved for wound healing
f. What is Infection?
i. Drainage that is odorous and purulent
2. Review the factors that alter the skin’s structure and function
a. Other disease process
i. Oxygenation and tissue perfusion
1. Any condition that affects the body’s ability to perfuse the tissue with
oxygen will adversely affect the wound healing
2. Smoking – increased risk – because of vasoconstriction
,b. Diabetes
i. Causes changes in the microvascular and macrovascular systems, leading to
thickening of the vessels wall and occlusion of blood flow with decreased supply
of nutrients and oxygen.
ii. Presence of a wound is accompanied by a reduction in collagen synthesis, a
decrease in strength of that collagen, impaired functioning of leukocytes, and a
reduction in the number and action of macrophages
c. Nutrition
i. Protein is needed by the fibroblasts for the purpose of synthesizing collagen
ii. Deficiencies in vitamin A and C along with trace minerals (zinc and copper)
negatively impact wound healing
d. The use of medications
i. Some medications affect wound healing which contributes to the older persons
risk for poor wound healing
e. External forces
i. Pressure
1. Pressure ulcers occur over bonny prominences
2. Factors that induce this: pressure intensity, the length the tissue has
pressure, intrinsic and extrinsic factors that affect the ability to withstand
or tolerate that pressure
ii. Shear – friction and gravity
iii. Aging
1. Decreased inflammatory response
2. Action of fibroblast and macrophages is reduced
a. Reducing collagen formation
f. Phases of Wound Healing
i. Inflammatory Phase
1. Begins with the bodies initial response to wounding of the skin and lasts
about 3 days
2. Bleeding occurs which triggers the coagulation cascade and the
formation of a clot to stop the bleeding
3. Increase in pain, redness, warmth, and swelling in the injured area as the
blood vessels dilate and leak fluid to tissue surrounding the injury
ii. Proliferate Phase
1. Repair of defect, filling in the wound bed with new tissue, and
resurfacing the wound with skin
2. Lasts several weeks
3. Involved development of new blood vessels (angiogenesis), that re
needed to support the new tissue, collagen synthesis, wound contraction,
and epithelialization
4. Epithelial cells proliferate and migrate laterally from the edges of the
wound until the wound has been resurfaced with epithelial cells
5. Granulation tissue- new tissue created to fill a wound, beefy appearance
because of newly created blood vessels
iii. Maturation Phase
, 1. Remodeling phase and can last up to a year
2. Collagen continues to be deposited and remodeled and the scar is formed
and strengthens
3. Scar tissue-avascular mass of collagen that gives strength to the repaired
wound
3. Discuss the components of a focused skin and wound assessment, including the use of risk
assessment tools
a. Focused health assessment includes: skins temperature, color, presence of excessive
moisture or dryness, odor, texture, turgor, and integrity.
i. After a baseline obtained, regular re-assessments should occur.
b. Braden scale and Norton Scale ranks certain risk factors for pressure ulcers
i. Braden Scale (1 being the worst, 4 being rarely affected)
1. Sensory Perception- ability to respond meaningfully to pressure related
discomfort
2. Moisture- degree to which the skin is exposed to moisture
3. Activity- degree of physical activity
4. Mobility- ability to change and control body position
5. Nutrition- usual food intake pattern
6. Friction and Shear
ii. Norton Scale (1 is bad, 4 is good)
1. Physical condition
2. Mental State
3. Activity
4. Mobility
5. Continence
c. Focused wound assessment
i. Evaluation of the wound’s location, size, and color; presence of drainage;
condition of wounds edges; characteristics of the wound bed; and the patient’s
response to the wound or wound treatment
ii. Location
1. use clear anatomic terminology for documentation purposes
iii. Size
1. consistency in wound measurements is important in accurately
monitoring progression toward healing
iv. Presence of undermining and tunneling:
1. Undermining: result of pressure and shear forces, this is often present in
sacral ulcers
2. Tunnels: increase the size of the wound, are a part of the wound. Lightly
gauze the area because the wounds heal from the edges inward and from
the bottom up.
v. Drainage
1. note whether drainage is present, the amount of drainage, the color,
consistency, and odor
vi. Conditions of wound edges and surrounding tissue –
Fundamentals II Exam 1
Chapter 29 – Wound Care (clean wounds)
1. Describe the normal structure and function of the skin
a. Epidermis
i. Regenerate 4-6 weeks
ii. Divided into more layers – corneum, lucidum, granulosum, spinosum, basale
b. Dermis
c. Subcutaneous layer
i. Layer of adipose tissue
ii. Delivers the blood supply to the dermis
iii. Provides insulation and has a cushioning effect
d. Factors affecting skin integrity
i. Wounds – disruptions in skin integrity
ii. Aging process
e. Need-to-know key terms
i. Dehiscence
1. Occurs when a wound fails to heal properly, and the layers of the skin
and tissue separate
a. Ex: Compliant by patient that something has given away can be
seen in a postoperative patient
2. It involves abdominal surgical wounds and occurs after a sudden strain,
such as coughing, vomiting, or sitting up in bed
ii. Evisceration
1. Seen when vital organs protrude through a wound opening
iii. Granulation
1. Red, moist tissue composed of new blood vessels, the presence of which
indicates progression toward healing
iv. Serous
1. Clear, watery fluid from plasma
v. Serosanguineous
1. Pink to pale and contains a mixture of serous and red, bloody fluid
vi. Sanguineous
1. Usually indicated bleeding and is bright red
vii. Purulent
1. Indicative of an infection and will need to be resolved for wound healing
f. What is Infection?
i. Drainage that is odorous and purulent
2. Review the factors that alter the skin’s structure and function
a. Other disease process
i. Oxygenation and tissue perfusion
1. Any condition that affects the body’s ability to perfuse the tissue with
oxygen will adversely affect the wound healing
2. Smoking – increased risk – because of vasoconstriction
,b. Diabetes
i. Causes changes in the microvascular and macrovascular systems, leading to
thickening of the vessels wall and occlusion of blood flow with decreased supply
of nutrients and oxygen.
ii. Presence of a wound is accompanied by a reduction in collagen synthesis, a
decrease in strength of that collagen, impaired functioning of leukocytes, and a
reduction in the number and action of macrophages
c. Nutrition
i. Protein is needed by the fibroblasts for the purpose of synthesizing collagen
ii. Deficiencies in vitamin A and C along with trace minerals (zinc and copper)
negatively impact wound healing
d. The use of medications
i. Some medications affect wound healing which contributes to the older persons
risk for poor wound healing
e. External forces
i. Pressure
1. Pressure ulcers occur over bonny prominences
2. Factors that induce this: pressure intensity, the length the tissue has
pressure, intrinsic and extrinsic factors that affect the ability to withstand
or tolerate that pressure
ii. Shear – friction and gravity
iii. Aging
1. Decreased inflammatory response
2. Action of fibroblast and macrophages is reduced
a. Reducing collagen formation
f. Phases of Wound Healing
i. Inflammatory Phase
1. Begins with the bodies initial response to wounding of the skin and lasts
about 3 days
2. Bleeding occurs which triggers the coagulation cascade and the
formation of a clot to stop the bleeding
3. Increase in pain, redness, warmth, and swelling in the injured area as the
blood vessels dilate and leak fluid to tissue surrounding the injury
ii. Proliferate Phase
1. Repair of defect, filling in the wound bed with new tissue, and
resurfacing the wound with skin
2. Lasts several weeks
3. Involved development of new blood vessels (angiogenesis), that re
needed to support the new tissue, collagen synthesis, wound contraction,
and epithelialization
4. Epithelial cells proliferate and migrate laterally from the edges of the
wound until the wound has been resurfaced with epithelial cells
5. Granulation tissue- new tissue created to fill a wound, beefy appearance
because of newly created blood vessels
iii. Maturation Phase
, 1. Remodeling phase and can last up to a year
2. Collagen continues to be deposited and remodeled and the scar is formed
and strengthens
3. Scar tissue-avascular mass of collagen that gives strength to the repaired
wound
3. Discuss the components of a focused skin and wound assessment, including the use of risk
assessment tools
a. Focused health assessment includes: skins temperature, color, presence of excessive
moisture or dryness, odor, texture, turgor, and integrity.
i. After a baseline obtained, regular re-assessments should occur.
b. Braden scale and Norton Scale ranks certain risk factors for pressure ulcers
i. Braden Scale (1 being the worst, 4 being rarely affected)
1. Sensory Perception- ability to respond meaningfully to pressure related
discomfort
2. Moisture- degree to which the skin is exposed to moisture
3. Activity- degree of physical activity
4. Mobility- ability to change and control body position
5. Nutrition- usual food intake pattern
6. Friction and Shear
ii. Norton Scale (1 is bad, 4 is good)
1. Physical condition
2. Mental State
3. Activity
4. Mobility
5. Continence
c. Focused wound assessment
i. Evaluation of the wound’s location, size, and color; presence of drainage;
condition of wounds edges; characteristics of the wound bed; and the patient’s
response to the wound or wound treatment
ii. Location
1. use clear anatomic terminology for documentation purposes
iii. Size
1. consistency in wound measurements is important in accurately
monitoring progression toward healing
iv. Presence of undermining and tunneling:
1. Undermining: result of pressure and shear forces, this is often present in
sacral ulcers
2. Tunnels: increase the size of the wound, are a part of the wound. Lightly
gauze the area because the wounds heal from the edges inward and from
the bottom up.
v. Drainage
1. note whether drainage is present, the amount of drainage, the color,
consistency, and odor
vi. Conditions of wound edges and surrounding tissue –
