NUR 205 EXAM 2 LATEST UPDATE 100% CORRECT

NUR 205 EXAM 2 LATEST UPDATE 100% CORRECT Largest Organ of the body The Skin Two layers of the skin Epidermis and Dermis Epidermis top layer of skin Stratum Corneum Outermost layer of the epidermis, which consists of flattened, keratinized cells Define Pressure Ulcers Described as impaired skin integrity related to unrelieved, prolonged pressure, usually over a boney prominence Pressure Ulcer Risk Factors -decreased mobility -decreased sensory perception -fecal or urinary incontinence -poor nutrition Individuals at risk for pressure ulcers -older adults that have experienced a trauma -those with spinal cord injuries -those who have sustained a fractured hip -those in long-term homes or community care, the acutely ill -individuals with diabetes -patients in critical care settings (ICU) Dermis inner layer of skin, provides tensile strength, mechanical support, and protection for the underlying muscles, bones, and organs Tissue Ischemia Pressure applied over a capillary exceeds the normal capillary pressure, and the vessel is occluded for a prolonged period of time. dermal-epidermal junction separates dermis and epidermis 3 pressure related factors that contribute to pressure ulcer development -pressure intensity -pressure duration -tissue tolerance Non-blanchable hyperemia redness that persists after palpation and indicates tissue damage Stage 1 Pressure Ulcer -intact skin with nonblanchable redness -warm to touch, edema, can be a hardened area Stage 2 Pressure Ulcer -partial thickness skin loss -shallow but open -no slough or drainage -red/pink wound bed