NUR 101 Final Exam Study Guide questions and answers

NUR 101 Final Exam Study GuideFactors that affect skin integrity - correct answer 1. age (turgor, drier, reduced collagen, more prone to injury)-frail skin 2. Bedrest/immobility-decrease pressure and shear 3. nutrition/hydration (protein, C, zinc, copper) 4. sensation level (diminished) 5. impaired circulation-(impaired arterial circulation causes muscle atrophy and thin tissue; impaired venous circulation causes buildup of waste in blood, causes edema, ulceration, skin breakdown)-loose clothing 6. moisture-incontinence, fever cause moisture and skin maceration (fever increases metabolic rate ans this tissue demand for oxygen) 7. Edema-decreases skin elasticity; compression stockings 8. Glycemic control-diabetes increases infection risk and delayed wound healing 9. Drugs-causes itching, rashes, photosensitivity, pigmentation changes; vasoconstrictors, steroids (inhibit wound healing); anticoagulants can result in pooling of blood in subcutaneous tissue, can cause hematoma; chemotherapeutic agents, antibiotics increase sensitivity to sun-sunburn 10. Impaired cognition 11. Infection-can contaminate a wound 12. Lifestyle-tanning, smoking (decreases oxygen supply to tissues, interferes with Vit c absorption necessary for collagen), body piercings, tattoos-risk for infection Nursing actions that limit the impact of the factors that alter skin integrity - correct answer 1. Anemia (poor 02 supply)-provide diet rich in iron 2. Nutrition deficits-provide supplements for vitamin c, protein, zinc, copper 3. Drugs (steroids, vasoconstrictors)-additional monitoring 4. Smoking-destroys granulation tissue (encourage/educate on cessation) 5. Mechanical friction-careful positioning, lifting equipment 6. Age-thinning of vascular circulation (protect fragile skin) 7. Obesity-Less blood supply in fatty tissue (monitor skin folds)