Skin Integrity and Wound Care: Analyze Cues and
Prioritize Hypotheses; Plan and Generate Solutions
Questions and Answers (100% pass)
Hypotheses related to skin integrity or wounds - ✔️✔️Are selected after the nurse links and
organizes relevant cues from physical assessment findings, observation, and signs and
symptoms of impaired skin.
Hypotheses are problems/alterations that the nurse needs to address to help the patient
improve.
To develop specific, individualized skin integrity or wound hypotheses, the nurse analyzes
cues by following these guidelines - ✔️✔️Determine relationship between cues
Organize and link cues
Consider relevance of cues
Determine relationship between cues - ✔️✔️Patient observation cues collected through
1. patient interview
2. physical assessment
3. including risk for pressure injuries and presence of wounds
4. observations of common skin integrity and wound alterations
Medical record cues collected through
1. review of the medical records
2. graphics record (flow sheet that uses a graph to record data)
3. laboratory results
Organize and link Cues - ✔️✔️Consider what is known about the patient and apply critical
thinking skills/judgment to cluster the cues and link them to the patients presentation
Categories for grouping cues
1. Presence of skin breakdown
2. type of wound
3. type of wound bed tissue
4. unexpected findings from assessment
5. findings from laboratory or diagnostic tests
Or a combination of these
Relevance of Cues - ✔️✔️Nurse must recognize other medical diseases, such as
1. Vascular diseases
2. obesity
3. diabetes
4. hyperthyroidism
Common Hypotheses related to skin integrity and wounds include - ✔️✔️Impaired skin
integrity, risk for impaired skin integrity
Impaired tissue integrity
Pressure ulcer/injury, risk for pressure ulcer/injury
inadequate knowledge of wound care
Difference between impaired skin integrity and impaired tissue integrity - ✔️✔️Skin integrity -
epidermis and dermis
Tissue integrity - relates to subcutaneous tissues and underlying structures
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