NSG 1010 Exam 4 Study Guide Solutions

NSG 1010 Exam 4 Study Guide Solutions Assessment of Integumentary Function/ Skin Integrity and Wound Healing - Ans:- Functions of the Skin - Ans:-Protection Temperature regulation Vitamin D production Sensation Fluid balance Immune response Psychosocial Absorption Health History - Ans:-Comorbid Conditions -Diabetes (decreased pain, foot ulcers) ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/15 -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 - Ans:-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 - Ans:-Pruritus- pt. complains of itching, rash Skin tears- document location, how long its been there ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/15 Edema- location and extent (+1, +2, etc.) Factors: -Infections -Mechanical (no wrinkles in sheets) -Chemical -Inflammatory (Lupus, Chrons) Assessment of Skin: Tissue Changes - Ans:-Partial thickness: epidermis/some dermis Full thickness: may extend to bone Think of burns and pressure wounds. Assessment of Skin: Skin Lesions - Ans:-Primary: direct result of cause Secondary: transformation of primary -Wounds Pustule (acne) Tumor (solid mass) ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 4/15 Nodule (raised above skin, can palpate-skin tag) Wheal (TB skin test, bee sting) Skin Lesion Configurations - Ans:-Linear (in a line) Annular and arciform (circular or arcing) Zosteriform (linear along a nerve route) Grouped (clustered) Discrete (separate and distinct) Confluent (merged) Gerontologic Considerations - Ans:-Thinning of skin Uneven pigmentation: age or liver spots Increased fragility and increased potential for injury Wrinkling Decreased elasticity Dry skin ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 5/15 Diminished hair Reduced healing ability: prevent injury from occurring Decreased mobility Diagnostic Procedures - Ans:-Tissue cultures Laboratory studies- CBC (infection), albumin (protein levels, nutritional levels, hair growth, subtleness of skin), blood cultures (infection of wounds/lesions) Doppler (for blood flow, any deficiencies?) Biopsy-key diagnostic (esp. for cancers, shave (skin), punch, and excisional) Nursing responsibilities (collecting, cultures/labs, patient prep, teaching, photographs) Drainage Devices - Ans:-Penrose or Close Suction Drain Hemovac/Jackson Pratt Use the term close suction drain, fluid is evacuated: penrose (inserted into incision to avoid buildup of wound infection, allow wound to heal and prevent re