Tissue integrity

Question 1

in order for the patient to have no issues with tissue integrity, they should have the antecedents :

Answer 1

good nutrition
lack of external trauma
adequate perfusion
limited pressure on site

from birth to death

Question 2

the ability of the body tissues to regenerate and or repair to maintain normal physiological processes

Answer 2

tissue integrity

Question 3

tool for assessing and predicting pressure ulcer

Answer 3

Braden scale

Question 4

largest organ of the body

Answer 4

skin

Question 5

the edge of the wound lines up and is well approximated

Answer 5

primary intention of wound healing

Question 6

granulation tissue fills the gap to close the wound ex: scab covering a wound

Answer 6

secondary intention of wound healing

Question 7

long term healing, under direct supervision, wound care management team. a wound that is closed much later.

ex: patient has surgery but the wound becomes infected and has to be reopened.

Answer 7

tertiary intention of wound healing

Question 8

skin hygiene
adequate nutrition
avoidance of excessive sun exposure
burn safety precautions
dermal ulcer prevention

Answer 8

clinical management

primary prevention

Question 9

Abcde for skin lesion

Answer 9

asymmetry

border

color

diameter

evolving

FYI: teach the patient to do this monthly

Question 10

nurse role to assess patient

nurses responsibilities

Answer 10

assessment

skin hygiene

wound care

medication administration

patient teaching

EX: teach diabetics to dry their feet in between the toes, potential for injury.