NSG300 / NSG 300 Exam 2
Student Exam 2 Blueprint
Foundations of Nursing - GCU
100% Guarantee Pass
TOPICS FEATURED
TOPIC 4: Skin and Wound Care
Chapter 48
TOPIC 5: The Nursing Process and Care Planning
Chapter 15-21
TOPIC 6: Nutrition, Fluids, Electrolytes, and Elimination
Chapter 42
, TOPIC 4: Skin and Wound Care
Chapter 48: skin integrity and wound care
4.1: Examine the factors that place clients at risk for impaired skin integrity
● Extrinsic Factors: shear, friction, moisture
● Systemic Factors: poor nutrition, aging, hydration status, low blood pressure
● Older adults aging skin:
○ Reduced skin elasticity
○ Decreased collagen
○ Thinning of underlying muscle and tissues causes easy tears in response to
mechanical trauma and shearing forces and tape removal
● Spinal cord injuries (SCI) and fractured hip injuries
● Patients in long-term homes or community care, acutely ill or hospice setting
● Individuals with diabetes
● Patients in critical care settings
● Imparied sensory perception for pain and pressure
● Imparied mobility
● Alteration in level of consciousness (comatose, confused/disoriented, aphasia)
● Shear force - sliding movement of skin
○ Ex: when the head of the bed is elevated and the sliding of the skeleton starts but
the skin is fixed because of friction with the bed
○ Transferring a patient from bed → stretcher
● Friction and moisture
● Factors influencing pressure ulcer formation and wound healing:
○ Nutrition, tissue perfusion, infection, age, psychosocial impact of wounds
○ Patients on steroids.
○ Systemic factors: age, anemia, hypoproteinemia, and zinc deficiency
● Surgical site infections risk factors:
○ Hyperglycemia, smoking, untreated peripheral vascular disease, obesity, age and
emergency surgery.
4.2: List the elements of a comprehensive wound assessment
● Identify location of the wound
● Determine etiology of wound (what caused it)
● Determine wound classification or stage
● Measure size of wound (length, width, and depth)
● Measure amount of wound tunneling and undermining
● Assess the wound bed, exudate, surrounding skin, wound edges, s/s of wound infection,
pain and document findings.
4.3: Identify the body’s key physiological defenses against infection
● Increased temperature release interferon
● Vasodilation in capillaries
● Primary acting white blood cell is Neutrophil which ingests bacteria and small debris
Student Exam 2 Blueprint
Foundations of Nursing - GCU
100% Guarantee Pass
TOPICS FEATURED
TOPIC 4: Skin and Wound Care
Chapter 48
TOPIC 5: The Nursing Process and Care Planning
Chapter 15-21
TOPIC 6: Nutrition, Fluids, Electrolytes, and Elimination
Chapter 42
, TOPIC 4: Skin and Wound Care
Chapter 48: skin integrity and wound care
4.1: Examine the factors that place clients at risk for impaired skin integrity
● Extrinsic Factors: shear, friction, moisture
● Systemic Factors: poor nutrition, aging, hydration status, low blood pressure
● Older adults aging skin:
○ Reduced skin elasticity
○ Decreased collagen
○ Thinning of underlying muscle and tissues causes easy tears in response to
mechanical trauma and shearing forces and tape removal
● Spinal cord injuries (SCI) and fractured hip injuries
● Patients in long-term homes or community care, acutely ill or hospice setting
● Individuals with diabetes
● Patients in critical care settings
● Imparied sensory perception for pain and pressure
● Imparied mobility
● Alteration in level of consciousness (comatose, confused/disoriented, aphasia)
● Shear force - sliding movement of skin
○ Ex: when the head of the bed is elevated and the sliding of the skeleton starts but
the skin is fixed because of friction with the bed
○ Transferring a patient from bed → stretcher
● Friction and moisture
● Factors influencing pressure ulcer formation and wound healing:
○ Nutrition, tissue perfusion, infection, age, psychosocial impact of wounds
○ Patients on steroids.
○ Systemic factors: age, anemia, hypoproteinemia, and zinc deficiency
● Surgical site infections risk factors:
○ Hyperglycemia, smoking, untreated peripheral vascular disease, obesity, age and
emergency surgery.
4.2: List the elements of a comprehensive wound assessment
● Identify location of the wound
● Determine etiology of wound (what caused it)
● Determine wound classification or stage
● Measure size of wound (length, width, and depth)
● Measure amount of wound tunneling and undermining
● Assess the wound bed, exudate, surrounding skin, wound edges, s/s of wound infection,
pain and document findings.
4.3: Identify the body’s key physiological defenses against infection
● Increased temperature release interferon
● Vasodilation in capillaries
● Primary acting white blood cell is Neutrophil which ingests bacteria and small debris
