Factors Affecting Skin Integrity and Pressure Ulcers
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Questions and Answers

Which factor does NOT affect skin integrity according to the text?

  • Age
  • Genetics
  • Types of wounds (correct)
  • Chronic illnesses

    • What is the largest organ in the body according to the text?

  • Heart
  • Liver
  • Lung
  • Skin (correct)

    • Which factor can impair skin integrity?

  • Good nutrition
  • Young age
  • Corticosteroids medication (correct)
  • Regular physical activity

    • What is one of the functions of intact skin according to the text?

    <p>Maintaining health</p> Signup and view all the answers

    Which condition makes skin on the legs damage more easily?

    <p>Impaired peripheral arterial circulation</p> Signup and view all the answers

    What type of wound is caused by accidental trauma?

    <p><strong>Unintentional</strong> wound</p> Signup and view all the answers

    Skin color and allergies are examples of factors related to which aspect of skin integrity?

    <p><strong>Genetics &amp; heredity</strong></p> Signup and view all the answers

    What is the impact of poor nutrition on skin integrity?

    <p><strong>Impairs skin integrity</strong></p> Signup and view all the answers

    In what way do chronic illnesses affect skin integrity?

    <p><strong>Impair peripheral arterial circulation</strong></p> Signup and view all the answers

    What is the main purpose of understanding factors affecting skin integrity for nurses?

    <p><strong>To prevent injury</strong></p> Signup and view all the answers

    What are some measures mentioned in the text to promote optimal skin condition?

    <p>Understanding factors affecting skin integrity</p> Signup and view all the answers

    Which medication is specifically highlighted in the text as affecting skin integrity?

    <p>Corticosteroids</p> Signup and view all the answers

    What is the maximum score on the Braden Scale?

    <p>23 points</p> Signup and view all the answers

    What does a Braden Scale score of ≤ 18 points indicate?

    <p>High risk</p> Signup and view all the answers

    Which of the following is NOT one of the subscales in the Braden Scale?

    <p>Moisture</p> Signup and view all the answers

    What is the main purpose of a Risk Assessment Tool in pressure ulcer prevention?

    <p>To identify individuals at risk for pressure ulcers</p> Signup and view all the answers

    What does a Norton Scale score between 14-10 indicate?

    <p>High risk</p> Signup and view all the answers

    In nursing management, what is assessed during the diagnosing phase related to skin integrity?

    <p>Color of the wound bed</p> Signup and view all the answers

    What is recommended for preventing pressure ulcers regarding skin hygiene?

    <p>Avoid hot water</p> Signup and view all the answers

    What is a common nursing intervention for preventing pressure ulcers related to repositioning?

    <p>Providing supportive devices like mattresses and pillows</p> Signup and view all the answers

    What should be done at each dressing change when treating a pressure ulcer?

    <p>Clean the ulcer and surrounding skin with surgical asepsis</p> Signup and view all the answers

    What should be considered for medication in the treatment of pressure ulcers?

    <p>Consider systemic antibiotics for evidence of infection</p> Signup and view all the answers

    What does a Norton Scale score > 18 indicate?

    <p>Low risk</p> Signup and view all the answers

    What is essential in assessing pressure ulcers regarding nursing management?

    <p>Color of the wound bed and location of necrosis</p> Signup and view all the answers

    Which type of wound involves accidental wounds and surgical wounds with a major break in sterile technique?

    <p>Contaminated wounds</p> Signup and view all the answers

    What does an 'Incision' type of wound involve?

    <p>Open wound with deep or shallow tissue penetration by a sharp instrument</p> Signup and view all the answers

    Which position is considered common for pressure ulcers?

    <p>Supine position</p> Signup and view all the answers

    What is the defining characteristic of Stage I pressure ulcers?

    <p>Non blanchable erythema</p> Signup and view all the answers

    Which type of wound involves tissue torn apart and often occurs from accidents?

    <p>Laceration</p> Signup and view all the answers

    What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?

    <p>Visible slough that obscures the depth of tissue loss</p> Signup and view all the answers

    What causes Pressure Ulcers?

    <p>Localized ischemia due to blood supply deficiency</p> Signup and view all the answers

    'Dirty or infected wounds' are characterized by:

    <p>Evidence of infection like purulent drainage</p> Signup and view all the answers

    Why is it important for nurses to understand the factors affecting skin integrity?

    <p>To promote optimal skin condition and prevent injury</p> Signup and view all the answers

    Which factor does NOT affect skin integrity according to the text?

    <p>Medication administration</p> Signup and view all the answers

    How do chronic illnesses affect skin integrity?

    <p>They impair peripheral arterial circulation leading to easy skin damage</p> Signup and view all the answers

    What aspect of skin integrity do skin color and allergies fall under?

    <p>Genetics &amp; heredity</p> Signup and view all the answers

    What should be done at each dressing change when treating a pressure ulcer?

    <p>Document the wound's progress</p> Signup and view all the answers

    What is the impact of poor nutrition on skin integrity?

    <p>It delays wound healing and impairs skin regeneration</p> Signup and view all the answers

    What type of wound is characterized by open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique?

    <p>Contaminated wounds</p> Signup and view all the answers

    In the context of wound classification, which wound type typically involves tissues that are torn apart and often occurs from accidents?

    <p>Laceration</p> Signup and view all the answers

    What does a 'Partial-thickness' wound involve?

    <p>Loss of epidermis and dermis</p> Signup and view all the answers

    Which position is NOT considered common as a pressure site leading to pressure ulcers?

    <p>Supine position</p> Signup and view all the answers

    What is the characteristic of a Stage II pressure ulcer?

    <p>Partial-thickness loss of epidermis and dermis</p> Signup and view all the answers

    What does 'Iatrogenesis' refer to in the context of describing wounds?

    <p>How the wounds were acquired</p> Signup and view all the answers

    What is the maximum score on the Norton Scale for assessing pressure ulcers?

    <p>20 points</p> Signup and view all the answers

    Which subscale is NOT part of the Braden Scale for pressure ulcer risk assessment?

    <p>Pain Perception</p> Signup and view all the answers

    In the context of pressure ulcers, what does 'Unstageable' mean?

    <p>Depth of ulcer obscured by slough or eschar</p> Signup and view all the answers

    What is the primary factor considered in determining a client's risk level according to the Norton Scale?

    <p>Mobility</p> Signup and view all the answers

    What is the significance of a Braden Scale score of 18 points?

    <p>Low risk for developing pressure ulcers</p> Signup and view all the answers

    What should be the first step in any pressure ulcer prevention model according to the text?

    <p>Using risk assessment tools</p> Signup and view all the answers

    How does the Norton Scale categorize individuals with scores between 14-10 points?

    <p>High risk for pressure ulcers</p> Signup and view all the answers

    Which factor is NOT mentioned as affecting skin integrity in the text?

    <p>Blood type</p> Signup and view all the answers

    What is the defining characteristic of a Stage II pressure ulcer according to the text?

    <p>Partial-thickness wound with a loss of dermis</p> Signup and view all the answers

    In what way do chronic illnesses impact skin integrity according to the text?

    <p>By making the skin on the legs prone to damage</p> Signup and view all the answers

    What type of wound is characterized by open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique?

    <p>Contaminated wound</p> Signup and view all the answers

    Which wound description involves an open wound penetrating the skin and often the underlying tissues by a sharp instrument?

    <p>Puncture</p> Signup and view all the answers

    What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?

    <p>Skin loss with necrosis or damage to tendon, muscle, or bone</p> Signup and view all the answers

    What is the maximum score on the Norton Scale for assessing pressure ulcers?

    <p>20 points</p> Signup and view all the answers

    What is the main purpose of using risk assessment tools in pressure ulcer prevention?

    <p>Identifying clients at risk</p> Signup and view all the answers

    What does 'Suspected deep tissue injury' in pressure ulcers refer to?

    <p>Purple or maroon area with intact skin</p> Signup and view all the answers

    What is an essential aspect of nursing intervention in treating pressure ulcers?

    <p>Repositioning the client regularly</p> Signup and view all the answers

    What is the maximum score on the Norton Scale for assessing pressure ulcers?

    <p>20 points</p> Signup and view all the answers

    In the Braden Scale, what is the significance of a score of 18 points?

    <p>At risk for pressure ulcers</p> Signup and view all the answers

    What is the primary factor considered in determining a client's risk level according to the Norton Scale?

    <p>General physical condition</p> Signup and view all the answers

    What is a common nursing intervention for preventing pressure ulcers related to repositioning?

    <p>Providing smooth and wrinkle-free foundation</p> Signup and view all the answers

    What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?

    <p>Loss of skin or tissue depth unknown</p> Signup and view all the answers

    What factors can affect skin integrity, as discussed in the text?

    <p>Chronic illnesses and medications like corticosteroids</p> Signup and view all the answers

    Why is it important for nurses to understand the factors affecting skin integrity?

    <p>To promote optimal skin condition and prevent injuries</p> Signup and view all the answers

    Which aspect of skin is impacted by poor nutrition according to the text?

    <p>Skin color and allergies</p> Signup and view all the answers

    How are 'clean-contaminated wounds' described in the text?

    <p>Uninfected wounds with minimal inflammation</p> Signup and view all the answers

    What is the characteristic of a 'Contusion' injury as described in the text?

    <p>It is a closed wound resulting in ecchymosis (bruising)</p> Signup and view all the answers

    Which factor contributes to Pressure Ulcers according to the text?

    <p>Decreased mobility</p> Signup and view all the answers

    What is the significance of a Braden Scale score of 23 points?

    <p>Low risk of developing pressure ulcers</p> Signup and view all the answers

    In the context of nursing management, what does 'Risk for Infection' imply?

    <p>The client is immunocompromised and prone to infection</p> Signup and view all the answers

    What is the main purpose of 'Preventing PUs' as mentioned in the text?

    <p>To implement strategies to avoid pressure ulcer development</p> Signup and view all the answers

    Which component is NOT part of the Braden Scale for assessing pressure ulcer risk?

    <p>Presence of slough or eschar</p> Signup and view all the answers

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