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NUR 120 Exam 2 Questions and Answers Latest Update
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NUR 120 Exam 2 Questions and Answers Latest Update
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NUR 120 Exam 2 Questions andAnswers Latest Update
why is the skin integrity important? - Answer--the skin is the largest organ in the human
body and it's the 1st line of defense (protective barrier)
How is the skin a protective barrier? - Answer-protects:
-the body from environmental threats( heat/cold UV)
-the body from physical trauma (covering organs, soft tissue, and blood vessels)
-the body from infection (barrier for infectious diseases)
-facilitates body temperature regulation (thermoregulation) (sweating)
having a good skin integrity means... - Answer-repair & recovery of skin when it is
exposed to injury or damage
why is wound care important? - Answer-*if done properly*
-prevents infection
-can lesson potential complications (scarring & traveling or full body infection)
how is healthy skin promoted? - Answer--self assessment( understanding the body's
skin patterns-moles, skin tags, bruising, scarring, and what is normal for the person)
-bathing (dependent on age, skin type, and environment)
-nutrition
-oral hydration
-sunscreen use (UV damage)
-skin moisturization habits
-perfusion (absence of certain diseases)
skin types - Answer-normal, dry, oily, combination
skin considerations for older adult - Answer--consider bathing every other day (too
much can dry out the skin or cause it to crack or peel)
-avoid hot water (can cause skin to dry or irritate skin & damage keratin in the skin cells)
-gently dry skin (aggressive rubbing can cause skin tearing)
-maintain adequate nutrition & hydration (minerals, H2O, & nutrients can promote good
skin integrity)
-avoid dehydration (excessive caffeine and/or alcohol can disrupt hydration of the skin)
considerations for dry skin - Answer--can affect anyone, but is dependent on external
factors:
-colder temp (seasonally-drier skin in the winter than summer)
-need for repeated washing (occupational-medical professionals)
-discuss w/ pt preferences for moisturization & skin hygiene routines:
,oils vs creams
hyaluronic acid
what are skin integrity problems? - Answer--environmental/socioeconomic conditions,
such as homelessness-increased potential for UV damage to the skin, exposure to the
elements (if wounded, potential lack of access to hygiene)
-sociocultural, skin "whitening" procedures can cause damage skin cells
what are some reasons for impaired skin integrity? - Answer--inflammatory disorders, ex
eczema, psoriasis
-vascular skin disorders, ex venous insufficiency, gangrene, frostbite
-lesions, damage to the skin through illness or injury.
(insect bites, infections ex. chickenpox/impetigo, burns, pressure ulcers, trauma,
tumors-benign/malignant, and surgery.
what are the basic wound classifications? - Answer-Time of healing
-acute wound: sudden onset, trauma related, heals quickly( less than 3 months) ex.
scrapping knee on pavement, cutting leg while shaving
-chronic wound: caused by chronic condition & takes more than 3 months to heal. ex.
diabetic foot ulcer, wound from radiation therapy
Skin tissue loss
-partial thickness wound: partial loss of skin laters, superficial & painful due to exposed
nerve endings. ex. 2nd degree burns where there is blisters, stage 2 pressure ulcer
-full thickness wound: total loss of epidermis and dermis, can involve subcutaneous
tissue and muscle, heals by complex process of scar formation. ex. stage 3 pressure
ulcer.
normal wound healing - Answer--INTENTIONS:
primary
secondary
tertiary
-Regeneration
-Scarring
what is primary intention? - Answer-*edges of incision are joined together*, primarily w/
sutures, steri-strips, or skin adhesive.( healing that occurs when a clean laceration or
surgical incision is made. well approx, edges fit together, straight cut)
ex. surgical incision, papercut, cutting hand w/ knife while cutting food.
what is secondary intention? - Answer-when a wound has a loss of tissue, *when a
wound is allowed to remain open and heal by granulation*, edges cannot be pulled
together.
, ex. stage 2 or 3 pressure ulcr
what is tertiary intention? - Answer-when a wound is allowed to remain open for a time
and then closed, allowing for debridement and other wound care - to reduce bacterial
counts prior to closure
wound irrigation - Answer-Flushing of an open wound using a medicated solution,
water, sterile saline, or an antimicrobial liquid preparation
what are the phases of wound healing? - Answer-inflammatory: cleaning & healing via
immune cells
proliferative: wound stable, wound begins to heal, creates granulation tissue, repairs
damaged vasculature feeding the skin
remodeling: wound mostly healed, body creates stronger skin to replace the temporary
tissue
Inflammatory phase - Answer-1-5 days
-damage control; makes sure wound is clean through immune cell deployment,
increases blood flow to the wound for necessary oxy & nutrients
Proliferative phase - Answer-6-21 days
-rebuilding phase; granulation tissue fills wound, contraction (wound shrinks b/c wound
edges pull together to reduce the size of the wound opening
Remodeling phase - Answer-3wks-2 years
-final phase, granulation tissue is replaced w/ stronger tissue (3 months) (tissue may
never be as strong as original skin-80% is optimal
-keloid scarring; hypertrophic scar, tissue extends beyond boundaries of the original
wound, common in specific skin types
keloid scar - Answer--can be common in African & Latin American descent
-familial based
what factors affect wound healing? - Answer-tissue profusion
-ischemia-deficient blood supply to body part
-environmental-smoking cigarettes
nutritional status
-diet-lack of protein (veganiam)
-alcoholism-lack of nutrients
diseases
-type 2 diabetes-effects tissue perfusion
-immunocompromised conditions-cancer, HIV(effects healing time)
anti-inflammatory medications
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