NSG 1010 Exam 4 Guide With
Complete Solution
Assessment of Integumentary Function/ Skin Integrity and Wound Healing
Functions of the Skin - ANSWER Protection
Temperature regulation
Vitamin D production
Sensation
Fluid balance
Immune response
Psychosocial
Absorption
Health History - ANSWER Comorbid Conditions
-Diabetes (decreased pain, foot ulcers)
-Heart disease/coronary artery disease (acute=pale pink, blue, purple) (nail
beds-cyanosis (hypoperfusion))
-Peripheral vascular disease- arterial insufficiency, skin will be dry, shiny, pale
to blue, alopecia (venous insufficiency- pale pink, edema, dermatitis, wounds
appear wet)
-Cancer- wounds are going to have excessive pain, an odor with drainage,
, may be bleeding/itching (very dark, black, necrotic looking, brown patches
on the skin (DRY)
Assessment of Skin: Color - ANSWER Pallor (related to anemia, decreased
blood flow/hemoglobin)
Hyperpigmentation/Hypopigmentation (vitiligo, hereditary? auto-immune?)
Cyanosis: emergency-situation maybe, perfusion issues, heart failure
Petechiae: red dots, circulatory issure
Erythema: ranges from bright pink to dusky to gray or cherry red (carbon
monoxide poisoning), inflammation
Brown: diabetes, venous insufficiency
Jaundice: check bilirubin levels (sclera in dark skinned individuals)
Assessment of Skin: Integrity - ANSWER Pruritus- pt. complains of itching,
rash
Skin tears- document location, how long its been there
Edema- location and extent (+1, +2, etc.)
Factors:
-Infections
-Mechanical (no wrinkles in sheets)
-Chemical
-Inflammatory (Lupus, Chrons)
Assessment of Skin: Tissue Changes - ANSWER Partial thickness:
Complete Solution
Assessment of Integumentary Function/ Skin Integrity and Wound Healing
Functions of the Skin - ANSWER Protection
Temperature regulation
Vitamin D production
Sensation
Fluid balance
Immune response
Psychosocial
Absorption
Health History - ANSWER Comorbid Conditions
-Diabetes (decreased pain, foot ulcers)
-Heart disease/coronary artery disease (acute=pale pink, blue, purple) (nail
beds-cyanosis (hypoperfusion))
-Peripheral vascular disease- arterial insufficiency, skin will be dry, shiny, pale
to blue, alopecia (venous insufficiency- pale pink, edema, dermatitis, wounds
appear wet)
-Cancer- wounds are going to have excessive pain, an odor with drainage,
, may be bleeding/itching (very dark, black, necrotic looking, brown patches
on the skin (DRY)
Assessment of Skin: Color - ANSWER Pallor (related to anemia, decreased
blood flow/hemoglobin)
Hyperpigmentation/Hypopigmentation (vitiligo, hereditary? auto-immune?)
Cyanosis: emergency-situation maybe, perfusion issues, heart failure
Petechiae: red dots, circulatory issure
Erythema: ranges from bright pink to dusky to gray or cherry red (carbon
monoxide poisoning), inflammation
Brown: diabetes, venous insufficiency
Jaundice: check bilirubin levels (sclera in dark skinned individuals)
Assessment of Skin: Integrity - ANSWER Pruritus- pt. complains of itching,
rash
Skin tears- document location, how long its been there
Edema- location and extent (+1, +2, etc.)
Factors:
-Infections
-Mechanical (no wrinkles in sheets)
-Chemical
-Inflammatory (Lupus, Chrons)
Assessment of Skin: Tissue Changes - ANSWER Partial thickness:
