NUR 1021 Exam 2 (100% error-free solutions)

Skin problems are most common in what age groups? correct answers Babies, teens, elderly What are some environmental factors that affect skin? correct answers Sun exposure, nutrition, stress, smoking, drugs, immobility, dehydration, diminished sensation Intensity (pressure ulcers) correct answers weight of pt, amount of intense pressure on a bony prominence Duration (pressure ulcers) correct answers How long has this pressure been on a bony prominence? Tissue tolerance (pressure ulcers) correct answers everyone is different, and sub Q can act as a cushion What are some risk factors for pressure ulcer development? correct answers impaired sensory perception, impaired mobility, alteration of LOC, shear, friction, moisture primary intention correct answers "wound" created during surgery (incision) edges are approximated, and heal more quickly secondary intention correct answers difficult to put back together, edges are usually rough (from a wound) have to heal from the inside out (ex: pressure ulcer) Pressure ulcer correct answers compression of skin and underlying soft tissue b/w bony prominence and external surface for extended period What are 3 mechanical forces that create pressure ulcers? correct answers pressure, friction and shear What are ways to prevent pressure ulcers? correct answers -identify high risk pts early using risk scale (braden scale) and do a nutritional assessment -implement aggressive intervention w/ pressure relief devices such as boots, special mattresses -repositioning pt and good skin care What are some contributing factors to pressure ulcers? correct answers -prolonged bedrest, altered mental status, incontinence, immobility, diabetes mellitus U Unstagable pressure ulcer correct answers Cannot see wound bed due to necrotic tissue or slough/eschar (must be cleaned before you determine the stage but typically a 3-4) Suspected deep tissue injury correct answers can see that skin is not healthy, may look like bruising. Have to wait until the skin breaks to see the damage before you can put it on a scale (typically a 3-4)