Prefinal - Skin Integrity

Question 1

is the body’s largest organ and is the primary defense against infection.

Answer 1

Skin

Question 2

A disruption in the integrity of body tissue

Answer 2

Wound

Question 3

Classification according to Wound Type:

Answer 3

Incised
Contusion
Punctured
Abrasions

Question 4

Classification of Wounds Thickness

Answer 4

Superficial
Deep

Question 5

Wounds that leave the deeper skin layers intact. These types of wounds are usually caused by friction rubbing against an abrasive surface.

Answer 5

Superficial (on the surface) wounds

Question 6

Wounds that go through all the layers of the skin and into underlying tissue like muscle or bone.

Answer 6

Deep wounds

Question 7

Factors Affecting Wound Healing

Answer 7

Age
Nutrition
Oxygenation
Smoking
Drug Therapy
Diabetes Miletus

Question 8

this Factor Affecting Wound Healing means that Although the elderly can heal most wounds, they have a slower healing process, and all phases of wound healing are also affected.

Answer 8

Age

Question 9

this Factor Affecting Wound Healing means that Optimal wound healing requires adequate nutrition. Nutrition deficiencies impede the normal processes that allow progression through stages of wound healing. Malnutrition has also been related to decreased wound tensile strength and increased infection rates.

Answer 9

Nutrition

Question 10

this Factor Affecting Wound Healing means that Oxygen plays a very significant role in wound healing – it is needed for cellular function and can kill bacteria and cause resistance to infection. Oxygen stimulates the creation of new blood vessels and also aids growth factors to form new skin. Your red blood cells carry oxygen throughout the body.

Answer 10

Oxygenation

Question 11

this Factor Affecting Wound Healing means that Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue.

Answer 11

Smoking

Question 12

this Factor Affecting Wound Healing means that The medications most likely to impair wound healing and damage skin integrity include antibiotics, anticonvulsants, steroids, and nonsteroidal anti-inflammatory drugs.

Answer 12

Drug Therapy

Question 13

this Factor Affecting Wound Healing means that Diabetes mellitus is one of the major contributors to chronic wound healing problems. When diabetic patients develop an ulcer, they become at high risk for major complications, including infection and amputation.



Answer 13

Diabetes Miletus

Question 14

(persistent bleeding) is abnormal and may indicate a slipped surgical suture, dislodged clot, or erosion of a blood vessel.

Answer 14

Hemorrhage

Question 15

Some bleeding from a wound is normal during and immediately after initial trauma and surgery.

Question 16

wound contamination

Answer 16

Infection

Question 17

Effects of Having a Wound



Answer 17

Dehiscence
Evisceration

Question 18

is the partial or complete separation of the wound edges and the layers below the skin.

Answer 18

Dehiscence

Question 19

occurs when the client’s viscera protrudes through the disrupted wound.

Answer 19

Evisceration

Question 20

Nursing Process for Altered Skin Integrity

Answer 20

Assessment of Wounds
Health history
Allergies to tape, latex, medications, or other substances
Physical examination
Location of wound
Size of wound
General appearance and drainage
Pain
Laboratory data

Question 21

ASSESSMENT TOOL:



Answer 21

A- anatomical location, Age of wound
S-size, Shape
S- sinus tract, Tunnelling, Undermining
E- exudate
S- sepsis (including odour)
S-surrounding skin
M-maceration
E-edge, Epithelialization
N-necrotic tissue
T-tissue bed, Tenderness (pain)
S-status- changes in condition, improvement

Question 22

Nursing Diagnoses

Answer 22

Impaired Tissue Integrity
Risk for Infection
Disturbed Body Image
Acute or Chronic Pain
Deficient Knowledge

Question 23

Outcome Identification and Planning

Answer 23

After my health teachings, the client will manifest positive receptivity/response to
health instructions
> wound begins to heal after a week
> gains weight at least 3 pounds a week
> bearable pain in the affected area

Question 24

Principles for Wound Dressing:

Answer 24

Use Standard Precautions at All Times
When using a swab or gauze to cleanse a wound, work from the clean area out toward the dirtier area.
When irrigating a wound, warm the solution to room temperature, preferably to body temperature, to prevent lowering of the tissue temperature.
Be sure to allow the irrigant to flow from the cleanest area to the contaminated area to avoid spreading pathogens.

Question 25

is the application of a hot agent, warmer than skin either in a moist or dry form on the surface of the body;

Answer 25

Hot application

Question 26

Purpose of Hot Application: 

Answer 26

To relieve pain and congestion To provide warmth To promote suppuration To promote healing To decrease muscle tone To soften the exudates

Question 27

is the application of a cold agent cooler than skin either in a moist or dry form, on the surface of the skin.

Answer 27

Cold application

Question 28

Purpose of Cold Application:

Answer 28

To reduce pain and body temperature, To anesthetize an area To control hemorrhage To control the growth of bacteria To prevent gangrene To prevent edema To reduce inflammation

Question 29

Local Dry Heat Examples:

Answer 29

Infrared Therapy Shortwave diathermy A heating pad Heating lamps

Question 30

Local Moist Heat Examples:

Answer 30

Hot bath A poultice Stupes A sitz bath Aquathermia pads A paraffin or wax bath

Question 31

to improve the healing of wounds, relieve pain, stiffness, and fatigue from rheumatoid arthritis

Answer 31

Infrared Therapy

Question 32

uses high-frequency electromagnetic energy to generate heat to treat pain from kidney stones, and PID.

Answer 32

Shortwave diathermy

Question 33

is used for the warming of parts of the body in order to manage pain

Answer 33

A heating pad

Question 34

increase blood circulation and hasten wound healing.

Answer 34

Heating lamps

Question 35

is for stress/ pain relief, muscle relaxation, improved sleep, and calorie burn.

Answer 35

Hot bath

Question 36

also called a cataplasm, is a paste made of herbs, plants, and other substances with healing properties.

Answer 36

A poultice

Question 37

is a hot, wet cloth or sponge with a medication for external application to lessen irritation/inflammation

Answer 37

Stupes

Question 38

is a warm water bath that helps to relieve pain from episiotomy wound (a surgical cut made between the vaginal opening and anus to aid in the delivery of the baby), hemorrhoids (painful and swollen blood vessels in the rectum or anus)

Answer 38

A sitz bath

Question 39

or blankets are useful in treating muscle sprains and for areas with mild inflammation or edema.

Answer 39

Aquathermia pads

Question 40

can also aid in healing problems with the skin.

Answer 40

A paraffin or wax bath

Question 41

General Dry Heat Examples:

Answer 41

Sunbathing Electric cradle or incubator

Question 42

protects a person against inflammation & improves memory.

Answer 42

Sunbathing

Question 43

provides an environment that can be adjusted to provide the ideal temperature as well as the perfect amount of oxygen, humidity, and light.

Answer 43

Electric cradle or incubator

Question 44

General Moist Heat Examples

Answer 44

Steam baths A whirlpool bath

Question 45

relieve tension, soothe nerve endings, relax muscles, and minimize joint pain, as well as minimize the pain of headaches due to the high-heat environment.

Answer 45

Steam baths

Question 46

reduces the amount of pain in the joints or muscles and improves body blood flow.

Answer 46

A whirlpool bath

Question 47

Local Dry Cold Examples

Answer 47

Ice bag Ice collar Ice pack (poultice) Ice cradle Chemical cold packs

Question 48

Local Moist Cold Examples

Answer 48

Ice to suck Cold compress Evaporating lotion

Question 49

General Dry Cold Example

Answer 49

Hypothermia

Question 50

General Moist Cold Examples

Answer 50

Cold sponging Cold bath Cold packs

Question 51

Other measures to relieve pain

Answer 51

> Contralateral stimulation