NURS 1503: FINAL EXAM QUESTIONS AND ACTUAL ANSWERS.
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Course
NURS 1503
Institution
NURS 1503
two layers of the skin - Answer - epidermis (thin outer layer; mainly connective tissue and few skin cells
- dermis (inner layer; provides protection of underlying muscles, bones and organs)
examples of skin-associated issues - Answer - age related changes (decreased collagen/elasticity)...
NURS 1503: FINAL EXAM QUESTIONS
AND ACTUAL ANSWERS.
two layers of the skin - Answer - epidermis (thin outer layer; mainly connective tissue and few skin cells
- dermis (inner layer; provides protection of underlying muscles, bones and organs)
examples of skin-associated issues - Answer - age related changes (decreased collagen/elasticity)
- attachment of dermis and epidermis become flat in older persons
- aging causes diminishes inflammatory response
- reduced nutritional intake
pressure injury - Answer localized damage to the skin and/or underlying soft tissue usually over a bony
prominence or related to a medical or other device
Three pressure related factors that contribute to pressure ulcer development - Answer pressure
intensity
pressure duration
tissue tolerance
pressure intensity - Answer -pressure exceeds normal capillary pressure (15-32mm)
-vessels occlude and tissue ischemia develops
-tissue may be damaged or tissue death may result
characteristics of dark skin at risk of skin breakdown - Answer - colour remains unchanged
- localized area may turn a purplish colour rather than red
- look in a natural light
- compare to surrounding skin
- warm to touch
- edema may occur
, - area may be sensitive and tender to touch
pressure duration - Answer - Low pressure over prolonged period of time &/or High pressure over a
short period of time
-pressures occur quickly (1-2hrs)
- occludes blood flow and nutrients and contributes to cell death
tissue tolerance - Answer - the ability of tissue to endure pressure depends on the integrity of the
tissue and the supporting structures
- extrinsic factors: shear friction and moisture
- poor nutrition, age and low blood pressure affect tissue tolerance
risk factors for pressure injury development - Answer - factors directly related to disease like decreased
consciousness, aftereffects of trauma and presence of cast
- braden scale helps to determine appropriate interventions
impaired sensory perception - Answer Patients with altered sensory perception for pain and pressure
are at risk because they cannot feel their body sensations
-may not feel prolonged pressure and are at risk
impaired mobility - Answer patients who are unable to independently change position are at risk
because they cannot change or shift off of bony prominences
alteration in level of consciousness - Answer - Patients who are confused or disoriented and those who
have expressive aphasia or other inability to verbalize or changing levels of consciousness are unable to
protect themselves from pressure ulcer development.
- Patients who are confused or disoriented are sometimes able to feel pressure but are not always able
to understand how to relieve it or communicate their discomfort.
- Patients in a coma cannot perceive pressure and are unable to move voluntarily to relieve pressure.
shear - Answer - force exerted parallel to the skin resulting both from gravity and from resistance
(friction) between the patient and a surface, such as that created when a patient slumps in a chair
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