Test bank for critical care nursing a holistic approach 12th edition by morton fontaine all chapters covered.pdf

COMPLETE TEST BANK FOR CRITICAL CARE
NURSING A HOLISTIC APPROACH 12TH
EDITION BY MORTON FONTAINE | ALL
CHAPTERS COVERED
1
Page

, Whatg1isg1theg1maing1functiong1ofg1skin?
- provideg1barrierg1againstg1injury,g1infection,g1UV,g1andg1fluctuationsg1ing1t
empg1changes
- Eliminateg1waste,g1supportg1underlyingg1structures,g1vitaming1Dg1synthesis
Threeg1layersg1ofg1sking1(outerg1tog1inner)
1. Epidermis
2. Dermis
3. Subcutaneous
Epidermis
outerg1mostg1layer
- protectsg1theg1body
- avascular
- keratinocytes,g1melanocytes,g1merkelg1cells,g1langerhansg1c
ellg1Keratinocytes
cellsg1functiong1tog1protectg1sking1fromg1waterg1loss,g1pathogens,g1andg1injury
- Formedg1ing1theg1basalg1layerg1(migrateg1tog1theg1top)
- Cellsg1dieg1andg1removedg1fromg1shedding
Markelg1cellsg1det
ectg1lightg1touchg1L
angerhansg1cells
epidermalg1macrophagesg1thatg1helpg1activateg1theg1immuneg1system
Dermis
supportg1dermisg1(nutrientsg1andg1support)
- Connectiveg1tissue,g1capillaries,g1bloodg1vessels,g1lymphg1vessels
- Supportsg1epidermisg1→g1strength,g1flexibili
tyg1(collageng1andg1elastin),g1nourishment
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g1 subcutaneous

, adiposeg1tissue
- Absorbsg1shockg1andg1padsg1internalg1organsg1(thermoregulationg1
andg1sensation)
Riskg1forg1impairedg1sking1integrity:g1neonatesg1andg1children
- Immatureg1skin,g1prolongedg1pressure,g1moisture,g1poorg1perfusion
- Problems:g1diaperg1rash,g1sking1tears,g1pressu
reg1injuries,g1maceration,g1and,g1dermatitisg1
Maceration
softeningg1ofg1tissueg1byg1soaking
dermatitis
irritationg1fromg1feces,g1urine,g1stomag1effluent,g1andg1woundg1secretionsg1leadingg1to
g1 inflamedg1andg1reddenedg1skin
Riskg1forg1impairedg1sking1integrity:g1olderg1adults
- Thinningg1ofg1sking1(decreasedg1hydration,g1bloodg1supply,g1elastic
ity,g1subq)g1decreasedg1collagen
- Problems:g1sking1tears,g1pressureg1injuries,g1itchy,g1dry,g1flakyg1skin,g1
sking1infections
Riskg1forg1impairedg1sking1integrity:g1immobileg1clients
- Decreasedg1circulation,g1thermoregulation,g1incontinence,g1lossg1
ofg1collagen,g1muscleg1atrophy,g1impairedg1sensation
- Problems:g1sking1tears,g1pressureg1injuries,g1sking1infection,g1dermat
itisg1(incontinence)
Riskg1forg1impairedg1sking1integrity:g1obesity
- Decreasedg1moisture,g1dryg1skin,g1maceration,g1increaseg1temp,g1decre
aseg1bloodg1/g1lymphg1flow
- Problems:g1Sking1tears,g1pressureg1injuries,g1diabeticg1ulcers,g1sking1
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foldg1rashes,g1moistureg1lesionsg1(alwaysg1checkg1ing1sking1folds)

, Riskg1forg1impairedg1sking1integrity:g1cancer
- Radiationg1→g1inflammation,g1sking1surfaceg1damage,g1decreasedg1bl
oodg1supply
- Problems:g1pressureg1injuries,g1delayedg1woundg1healing,g1sking1infecti
on,g1dermatitis
Riskg1forg1sking1breakdown:g1chronicg1illness
- Hepatic,g1renal,g1cardiovascular,g1malnutrition,g1stomas,g1psychosocial
- Problems:g1sking1tears,g1pressureg1ulcers,g1infection,g1moistureg1associat
edg1lesions
Conditionsg1thatg1increaseg1riskg1ofg1sking1breakdown
- Diabetes,g1obesity,g1cancer,g1liverg1failure,g1kidneyg1disease
- Mobility:g1spinag1bifida,g1paraplegia,g1cerebralg1pal
syg1Sking1assessment
Parts:g1Medicalg1Hx,g1riskg1factors,g1assessingg1sking1forg1abrasions,g1edema,g1
moisture,g1abnormalities,g1sking1textureg1/g1temperature
- Determineg1riskg1ofg1pressureg1injury,g1classifyg1wound,g1determineg1treatm
entg1modalities
- Sking1assessmentsg1shouldg1beg1doneg1dailyg1org1qg1s
hiftg1Pressureg1injury
localizedg1damageg1tog1theg1sking1and/org1underlyingg1tissue,g1asg1ag1resultg1ofg1
ag1pressureg1org1pressureg1andg1shear
Erythema
rednessg1ofg1sking1dueg1tog1dilationg1ofg1bloodg1vesselsg1(commong1overg1bonyg1pro
minences)
Blanchableg1erythema
rednessg1becomeg1temporarilyg1whiteg1withg1pressureg1Nonblanch
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ableg1erythema