NUR 155
EXAM 3 STUDY GUIDE
Foundations of Nursing
Galen College of Nursing
,
, NUR 155 Unit 6 CH29, CH37 pp. 916-917 (11-13 questions)
Chapter 29 Skin Integrity and Wound Care
Normal Structure and Function of Skin
Factors affecting skin integrity
● Wounds
○ Post-op wounds
○ Pressure injuries
● Vascular disease
○ Poor circulation has wounds
● Diabetes
● Malnutrition
● Age
○ Older increases risk for pressure injuries
Medical adhesive-related skin injuries (MARSI)
● Occur when superficial layers of skin are removed by medical adhesive
● SAFETY ALERT: remove products with strong adhesive backing, such as that
found in tapes and adhesive dressings, carefully from the elderly person’s skin to
prevent stripping of the epidermis
Altered Structure and Functions of the Skin
Wound Classification
○ Skin integrity
■ Open wound: a break in the skin. a puncture wound (stabbing), an
abrasion, a surgical incision
■ Closed wound: bruising, skin still intact
○ Wound depth
■ Measure with a Q-tip
○ Amount of contamination
■ Clean wound: ex: surgical wound since down in a sterile environment
■ Clean contaminated wound: surgery involves organ systems that are
likely to contain bacteria, the risk for infection is greater
● Ex: abdominal surgery
■ Contaminated wound: break during sterile, perforation of an organ
■ Infected wound: redness, warmth, and increased drainage that may or
may not be purulent (pus)
○ Healing process
■ Primary
● Approximated: together. Most simplest. Acute wounds.
■ Secondary
● Chronic wounds, wounds that can’t be brought together, new
tissue must fill in from the bottom and sides of the wound. It has to
remain open. High risk for infection since it can’t be closed
EXAM 3 STUDY GUIDE
Foundations of Nursing
Galen College of Nursing
,
, NUR 155 Unit 6 CH29, CH37 pp. 916-917 (11-13 questions)
Chapter 29 Skin Integrity and Wound Care
Normal Structure and Function of Skin
Factors affecting skin integrity
● Wounds
○ Post-op wounds
○ Pressure injuries
● Vascular disease
○ Poor circulation has wounds
● Diabetes
● Malnutrition
● Age
○ Older increases risk for pressure injuries
Medical adhesive-related skin injuries (MARSI)
● Occur when superficial layers of skin are removed by medical adhesive
● SAFETY ALERT: remove products with strong adhesive backing, such as that
found in tapes and adhesive dressings, carefully from the elderly person’s skin to
prevent stripping of the epidermis
Altered Structure and Functions of the Skin
Wound Classification
○ Skin integrity
■ Open wound: a break in the skin. a puncture wound (stabbing), an
abrasion, a surgical incision
■ Closed wound: bruising, skin still intact
○ Wound depth
■ Measure with a Q-tip
○ Amount of contamination
■ Clean wound: ex: surgical wound since down in a sterile environment
■ Clean contaminated wound: surgery involves organ systems that are
likely to contain bacteria, the risk for infection is greater
● Ex: abdominal surgery
■ Contaminated wound: break during sterile, perforation of an organ
■ Infected wound: redness, warmth, and increased drainage that may or
may not be purulent (pus)
○ Healing process
■ Primary
● Approximated: together. Most simplest. Acute wounds.
■ Secondary
● Chronic wounds, wounds that can’t be brought together, new
tissue must fill in from the bottom and sides of the wound. It has to
remain open. High risk for infection since it can’t be closed
