NUR 101 FINAL EXAM STUDY GUIDE COMPLETE QUESTIONS AND VERIFIED ACCURATE SOLUTION (DETAILED & ELABORATED) |100% ACCURATE!! TEST!!

NUR 101 FINAL EXAM STUDY GUIDE COMPLETE QUESTIONS AND VERIFIED ACCURATE SOLUTION (DETAILED & ELABORATED) |100% ACCURATE!! TEST!! Factors that affect skin integrity Answer 1. age (turgor, drier, reduced collagen, more prone to injury) frail skin 2. Bedrest/immobility-decrease pressure and shear 3. nutrition/hydration (protein, C, zinc, copper) 4. sensation level (diminished) 5. impaired circulation-(impaired arterial circulation causes muscle atrophy and thin tissue; impaired venous circulation causes buildup of waste in blood, causes edema, ulceration, skin breakdown)-loose clothing 6. moisture-incontinence, fever cause moisture and skin maceration (fever increases metabolic rate ans this tissue demand for oxygen) 7. Edema-decreases skin elasticity; compression stockings 8. Glycemic control-diabetes increases infection risk and delayed wound healing 9. Drugs-causes itching, rashes, photosensitivity, pigmentation changes; vasoconstrictors, steroids (inhibit wound healing); anticoagulants can result in pooling of blood in subcutaneous tissue, can cause hematoma; chemotherapeutic agents, antibiotics increase sensitivity to sun-sunburn 10. Impaired cognition 11. Infection-can contaminate a wound 12. Lifestyle-tanning, smoking (decreases oxygen supply to tissues, interferes with Vit c absorption necessary for collagen), body piercings, tattoos-risk for infection Nursing actions that limit the impact of the factors that alter skin integrity Answer 1. Anemia (poor 02 supply)-provide diet rich in iron 2. Nutrition deficits-provide supplements for vitamin c, protein, zinc, copper 3. Drugs (steroids, vasoconstrictors)-additional monitoring 4. Smoking-destroys granulation tissue (encourage/educate on cessation) 5. Mechanical friction-careful positioning, lifting equipment 6. Age-thinning of vascular circulation (protect fragile skin) 7. Obesity-Less blood supply in fatty tissue (monitor skin folds) 8. Diabetes-decreased oxygen, poor capillary growth, impaired phagocytosis)-increase glycemic control Braden Scale Answer Pressure ulcers lower the number, higher the risk 4-23 less than 17 = risk for pressure ulcers List the characteristics used to classify wounds Answer 1. Skin integrity (open and closed wound) -closed (bruise or tissue swelling from fracture) -open (abrasion, laceration, puncture wound, surgical incision, compound fracture) 2. Length of time for healing-acute (healing progresses normally) and chronic (delayed healing due to infection, trauma, ischemia, edema)-diabetic ulcers, pressure injury; lingers for months or years 3. Level of contamination (CDC) -clean -uninfected, no inflammation, closed, no tracts are entered -clean-contaminated-resp, genital, urinary, alimentary tracts are entered, no evid. of infection -contaminated-open, fresh accidental wounds -dirty-infected- 4. Depth of wound-superficial (epidermal-friction, shearing, burning); Partial thickness (epidermis but not through dermis; full thickness (extend into subcutaneous) Wound types Answer 1. intentional-surgical -incision (sharp instrument) 2. unintentional-cut, trauma, pressure ulcer -abrasion (scrape of superficial layers) -abscess-pus due to entry of microbe -contusion (bruise) -crushing (compression of tissue-fracture of bone) -Laceration (tear in skin) -penetrating (open wound with object lodged in tissue) -Puncture (open wound caused by sharp obj-prone to infection) -tunnel (entrance and exit site) Signs of wound infection include Answer erythema, swelling, fever, foul smell, pain, drainage, warmth Wound healing Answer epithelia, endothelial, inflammatory cells, platelets, fibroblasts migrate into wound -age, wellness, decreased leukocyte count, infection, some medications, nutrition, tissue perfusion, low Hgb levels, obesity, chronic diseases, smoking, wound stress (vomiting, coughing), poor wound care, all affect healing Types of healing Answer 1. Regenerative/epithelial: wound affects only epidermis and dermis; no scar; epidermal and dermal cells form new skin identical to original skin 2. Primary (first) intention healing: wound has minimal/no tissue loss, edges are well approximated; Little scarring; clean incision heals this way; scar tissue is only 80% as strong as orig tissue; wound edges are reapproximated (brought together); approximation is performed with sutures, staples, or adhesive tape or glue 3. Secondary intention healing: extensive tissue loss preventing wound edges from approximating or is not closed due to risk of infection; granulation tissue forms (heals slowly, more prone to infection develops more scar tissue); heals from the base upwards; may intentionally be left open or surgical dehiscence 4. Tertiary intention healing: delayed primary closure; 2 tissues of granulation are brought together through suturing, staples, or graft; occurs when wound is clean contaminated or contaminated; less scarring than secondary intention; Stages of the wound healing process Answer 1. inflammatory phase (4-6 days) -hemostasis and inflammation -hemostasis: tissues and capillaries are destroyed, blood and plasma leaks into tissues; blood vessels constrict to limit blood loss, platelets clump to slow bleeding; clotting mechanism activated -inflammation: edema, erythema, pain, temp elevation, redness, loss of function, migration of WBC's into tissues, microphages engulf bacteria (phagocytosis), clear debris. Form scab on wound with proteins & fibrin to seal wound; release of histamine, bradykinin, prostaglandins; vasodilation & increased permeability of capillaries 2. proliferative phase (granulation): days 5-24 -Fibroblasts enter wound (connective tissue) -collagen synthesis -new blood & lymph vessels form to form granulation tissue -epithelial proliferation & migration-epithelial cells from surrounding tissue seals the wound (epithelialization) 3. Maturation phase: epithelialization (remodeling) -2nd/3rd week -continues 3-6 months -formation of scar tissue -contraction of wound (shrinkage) Wound drainage Answer -serous (clear)-watery, little cellular matter, serum, clean wound -sanguineous (bloody)-damage to capillaries, deep wounds or wounds in vascular areas -serosanguineous-bloody and serous (commonly seen in new wounds) -purulent-thick, malodorous, infected, pus (WBCs, debris, bacteria)-streptococci or staphylocci -purosanguineous-red tinged pus; small vessels have ruptured Factors that lead to pressure ulcers Answer -poor circulation -reduced oxygen supply in blood (tobacco or anemic) -limited mobility -limited sensation (nerve damage, head injury, stroke, spinal cord injury, diabetes) -poor nutrition -fever -infection -dehydration -edema -health status -friction -shearing -moisture Signs of a suspected tissue injury Answer -purple maroonized area of discolored skin or blood filled blister, caused by damage to skin due to pressure or shear -painful, firm, mushy, boggy, warmer, cooler, compared to adjacent tissue -may evolve rapidly to expose additional layers of tissue -harder to detect in patients with dark skin