NURS 236 Exam 3 Guide With
Complete Solution
Structure of the skin - ANSWER Largest organ of the body.
Essential for maintaining life.
Two layers:
-Epidermis
-Dermis
· Rests on subcutaneous tissue.
· These layers become thin
What happens to the functions of the skin as we age? - ANSWER -decrease
-harder to regulate
Functions of the skin - ANSWER Protection - barrier
Temperature regulation = compensated for both heat and cold
Psychosocial - external appearance
Sensation - touch, pain, pressure, temperature
Vitamin D production - activated by UV rays from the sun
Immunologic - triggered when skin is broken
Absorption - medications
,Elimination - sweat (water, electrolytes, and nitrogenous wastes)
Factors Affecting Skin Integrity - ANSWER - Developmental considerations
- Changes in Health state
Developmental Considerations - skin integrity - ANSWER Infant
- Fragile, high risk for injury and infection
Child
- Becomes increasingly resistant to injury and infection
Older adult
- Easily damaged
Changes in health state - ANSWER Dehydration or Malnutrition
-If fluid, protein and vitamin C is deficient...
· Skin loses elasticity and becomes prone to breakdown.
Reduced Sensation (paralysis, nerve damage)
-If patient has an inability to sense temperature extremes, pressure, and
friction...
· Not able to heal > can cause paraplegia/quadriplegia
· Increased risk for injury (commonly a pressure injury)
Aging adult - skin integrity - ANSWER Subcutaneous and dermal tissues
become thin.
- Increased risk for injury.
,- Less capacity to insulate.
- Sensation of pressure and pain is reduced.
Activity of the sebaceous and sweat glands decreases.
- Skin is dryer and itching may occur.
Cell renewal is decreased.
- Prolonged healing time.
Collagen fibers is less organized.
- Skin loses elasticity.
Chronic Condition - diabetic foot ulcer - ANSWER diabetes
- Cuts and sores that don't heal.
- Lesions on the lower extremities that ulcerate and become necrotic.
- Recurrent bacterial and fungal infections.
Keeping in mind the layers of the skin and the function of the skin, what is
compromised for individuals with diabetes? What is causing this? - ANSWER
Compromised skin integrity due to instability with blood glucose levels,
vascular problems > delayed healing
Bed Rest - ANSWER Increased risk for skin breakdown > Reposition pt
Cast - ANSWER Irritant to the skin
> Assessment for breakdown
Medications - ANSWER - Allergic skin reactions (rashes)
- Photosensitivity
, - Impaired healing > Assessing skin color, rashes, are they flat?
Radiation Therapy - ANSWER Redness, Dry skin, Burns, Rashes > Education
on what to expect and what creams to use/avoid
Wounds - ANSWER Break or disruption in the normal integrity of the skin
and tissues.
May result from:
-Mechanical forces (Surgical incision), Physical injury (Burn)
-Underlying conditions:
· Pressure ulcer - compromised circulation r/t pressure
· Venous ulcer - injury and poor venous return r/t incompetent valves
· Arterial ulcer - injury and underlying ischemia r/t atherosclerosis or
thrombosis
· Diabetic ulcer - injury and underlying diabetic neuropathy, peripheral
artery disease
Would the following wounds be considered acute or chronic (hint: keep in
mind what is causing the ulcer)?
- Pressure ulcer, venous ulcer, arterial ulcer, and diabetic ulcer - ANSWER
Chronic
Intentional Wounds - ANSWER Result of a planned invasive
therapy/treatment.
Purposefully created.
Edges are clean and bleeding is controlled.
Complete Solution
Structure of the skin - ANSWER Largest organ of the body.
Essential for maintaining life.
Two layers:
-Epidermis
-Dermis
· Rests on subcutaneous tissue.
· These layers become thin
What happens to the functions of the skin as we age? - ANSWER -decrease
-harder to regulate
Functions of the skin - ANSWER Protection - barrier
Temperature regulation = compensated for both heat and cold
Psychosocial - external appearance
Sensation - touch, pain, pressure, temperature
Vitamin D production - activated by UV rays from the sun
Immunologic - triggered when skin is broken
Absorption - medications
,Elimination - sweat (water, electrolytes, and nitrogenous wastes)
Factors Affecting Skin Integrity - ANSWER - Developmental considerations
- Changes in Health state
Developmental Considerations - skin integrity - ANSWER Infant
- Fragile, high risk for injury and infection
Child
- Becomes increasingly resistant to injury and infection
Older adult
- Easily damaged
Changes in health state - ANSWER Dehydration or Malnutrition
-If fluid, protein and vitamin C is deficient...
· Skin loses elasticity and becomes prone to breakdown.
Reduced Sensation (paralysis, nerve damage)
-If patient has an inability to sense temperature extremes, pressure, and
friction...
· Not able to heal > can cause paraplegia/quadriplegia
· Increased risk for injury (commonly a pressure injury)
Aging adult - skin integrity - ANSWER Subcutaneous and dermal tissues
become thin.
- Increased risk for injury.
,- Less capacity to insulate.
- Sensation of pressure and pain is reduced.
Activity of the sebaceous and sweat glands decreases.
- Skin is dryer and itching may occur.
Cell renewal is decreased.
- Prolonged healing time.
Collagen fibers is less organized.
- Skin loses elasticity.
Chronic Condition - diabetic foot ulcer - ANSWER diabetes
- Cuts and sores that don't heal.
- Lesions on the lower extremities that ulcerate and become necrotic.
- Recurrent bacterial and fungal infections.
Keeping in mind the layers of the skin and the function of the skin, what is
compromised for individuals with diabetes? What is causing this? - ANSWER
Compromised skin integrity due to instability with blood glucose levels,
vascular problems > delayed healing
Bed Rest - ANSWER Increased risk for skin breakdown > Reposition pt
Cast - ANSWER Irritant to the skin
> Assessment for breakdown
Medications - ANSWER - Allergic skin reactions (rashes)
- Photosensitivity
, - Impaired healing > Assessing skin color, rashes, are they flat?
Radiation Therapy - ANSWER Redness, Dry skin, Burns, Rashes > Education
on what to expect and what creams to use/avoid
Wounds - ANSWER Break or disruption in the normal integrity of the skin
and tissues.
May result from:
-Mechanical forces (Surgical incision), Physical injury (Burn)
-Underlying conditions:
· Pressure ulcer - compromised circulation r/t pressure
· Venous ulcer - injury and poor venous return r/t incompetent valves
· Arterial ulcer - injury and underlying ischemia r/t atherosclerosis or
thrombosis
· Diabetic ulcer - injury and underlying diabetic neuropathy, peripheral
artery disease
Would the following wounds be considered acute or chronic (hint: keep in
mind what is causing the ulcer)?
- Pressure ulcer, venous ulcer, arterial ulcer, and diabetic ulcer - ANSWER
Chronic
Intentional Wounds - ANSWER Result of a planned invasive
therapy/treatment.
Purposefully created.
Edges are clean and bleeding is controlled.
