NUR 109 :NUR 109 Skin Assessment/Wound care: Questions & Answers: Guaranteed A+ Guide

NUR109 Skin Assessment/Wound care: Questions &
Answers
Diabetic foot ulcers; cause, location. and risk factors
(Ans-
Causes- Peripheral neuropathy
Peripheral vascular disease with poor microvascular circulation
Location- Toes, Sole of foot
Risk Factors- visual neuropathy, smoking.


Diabetic foot ulcers; Associated Skin Assessment
(Ans-
↓ sensation in foot
Warm skin, may be dry
Plantar fat pad atrophy
Foot deformities such as hammer toe, claw toe, and Charcot's foot


Diabetic foot ulcers; wound characteristics
(Ans-
Regular wound margins
Often surrounded by a rim of calloused tissue
Variable depth

,Drainage: Low to moderate amount


Pressure injury; cause, location, risk factors
(Ans-
Cause - Result of intense and/or prolonged pressure or pressure in
combination with shear
Location- Typically over bony prominences or under medical equipment
Risk Factors- Perpendicular pressure on vascularity. Blood vessels get
flat which limits blood flow to the area. Intrinsic and Extrinsic


Intrinsic factors of pressure injuries
(Ans-
Immobility
Impaired sensation
Malnourishment
Aging
Fever
Infection
Dehydration

, Extrinsic factors of pressure injuries
(Ans-
Friction
Pressure
Shearing
Exposure to moisture


Pressure injury; Associated Skin Assessment (Periwound)
(Ans-
Possible
Maceration
Erythema
Excoriation
Induration
Fluctuance


Pressure injury; Wound Characteristics
(Ans-
Localized damage to skin and/or underlying soft tissue usually over a
bony prominence or related to a medical device
Presents as intact skin or an open ulcer