Nursing Essentials exam 2

1. Functions of the skin?: Protection, body temp regulation, psychosocial, sen- sation, vit d production, Immunological, absorption, elimination. 2. What are adequately nourished and hydrated body cells resistant to?: In- jury. 3. Why do the elderly have problems with their skin?: Loss of lean body mass, Loss of elasticity, Regeneration of skin takes longer, reduced collagen. 4. Open wound: Skin is Broken 5. Closed wound: Ex. Bruises, broken ribs etc...skin is not broken 6. Intentional wound: Surgical 7. Unintentional wound: Falling down and getting a cut 8. Partial thickness wound: loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. 9. Full thickness wound: Skin loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. 10. Complex wound: Mixture of Partial and full thickness. 11. Phases of wound healing: Hemostasis, Inflammatory phase, Proliferation phase, maturation. 12. Hemostasis: Occurs immediately, clotting begins, Exudate is formed causing swelling and pain, Increased perfusion results in heat and redness, platelets stimulate other cells to migrate to the injury to participate in other phases of healing. 13. Inflammatory Phase: Lasts 3-6 days, prepares wound for healing i.e. Leuko- cytes, macrophages, Acute inflammation, increased temp and malaise. 14. Proliferation phase: Begins within 2-3 days, lasts up to 2-3 weeks, new tissue is built through fibroblasts, Capillaries grow across wound, thin layer of epithelial cells forms across wound, Granulation tissue forms a foundation for scar tissue development. 15. Maturation Phase: 3 weeks after injury, continues for months/years, collagen is remodeled, new collagen tissue is deposited, scar becomes a flat, thin, white line. 16. Primary intention and wound repair: Intentional wound, edges well approx- imated, minimal tissue loss and scaring. 17. Secondary intention and wound repair: Edges not well approximated, large open wounds, burns or major trauma, contaminated or infected, take longer and have more scar tissue.