Factors Affecting Skin Integrity and Pressure Ulcers

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

Types of wounds

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

Skin

Which factor can impair skin integrity?

Corticosteroids medication

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

Maintaining health

Which condition makes skin on the legs damage more easily?

Impaired peripheral arterial circulation

What type of wound is caused by accidental trauma?

Unintentional wound

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

Genetics & heredity

What is the impact of poor nutrition on skin integrity?

Impairs skin integrity

In what way do chronic illnesses affect skin integrity?

Impair peripheral arterial circulation

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

To prevent injury

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

Understanding factors affecting skin integrity

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

Corticosteroids

What is the maximum score on the Braden Scale?

23 points

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

High risk

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

Moisture

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

To identify individuals at risk for pressure ulcers

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

High risk

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

Color of the wound bed

What is recommended for preventing pressure ulcers regarding skin hygiene?

Avoid hot water

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

Providing supportive devices like mattresses and pillows

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

Clean the ulcer and surrounding skin with surgical asepsis

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

Consider systemic antibiotics for evidence of infection

What does a Norton Scale score > 18 indicate?

Low risk

What is essential in assessing pressure ulcers regarding nursing management?

Color of the wound bed and location of necrosis

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

Contaminated wounds

What does an 'Incision' type of wound involve?

Open wound with deep or shallow tissue penetration by a sharp instrument

Which position is considered common for pressure ulcers?

Supine position

What is the defining characteristic of Stage I pressure ulcers?

Non blanchable erythema

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

Laceration

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

Visible slough that obscures the depth of tissue loss

What causes Pressure Ulcers?

Localized ischemia due to blood supply deficiency

'Dirty or infected wounds' are characterized by:

Evidence of infection like purulent drainage

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

To promote optimal skin condition and prevent injury

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

Medication administration

How do chronic illnesses affect skin integrity?

They impair peripheral arterial circulation leading to easy skin damage

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

Genetics & heredity

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

Document the wound's progress

What is the impact of poor nutrition on skin integrity?

It delays wound healing and impairs skin regeneration

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

Contaminated wounds

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

Laceration

What does a 'Partial-thickness' wound involve?

Loss of epidermis and dermis

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

Supine position

What is the characteristic of a Stage II pressure ulcer?

Partial-thickness loss of epidermis and dermis

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

How the wounds were acquired

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

20 points

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

Pain Perception

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

Depth of ulcer obscured by slough or eschar

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

Mobility

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

Low risk for developing pressure ulcers

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

Using risk assessment tools

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

High risk for pressure ulcers

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

Blood type

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

Partial-thickness wound with a loss of dermis

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

By making the skin on the legs prone to damage

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

Contaminated wound

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

Puncture

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

Skin loss with necrosis or damage to tendon, muscle, or bone

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

20 points

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

Identifying clients at risk

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

Purple or maroon area with intact skin

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

Repositioning the client regularly

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

20 points

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

At risk for pressure ulcers

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

General physical condition

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

Providing smooth and wrinkle-free foundation

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

Loss of skin or tissue depth unknown

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

Chronic illnesses and medications like corticosteroids

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

To promote optimal skin condition and prevent injuries

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

Skin color and allergies

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

Uninfected wounds with minimal inflammation

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

It is a closed wound resulting in ecchymosis (bruising)

Which factor contributes to Pressure Ulcers according to the text?

Decreased mobility

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

Low risk of developing pressure ulcers

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

The client is immunocompromised and prone to infection

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

To implement strategies to avoid pressure ulcer development

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

Presence of slough or eschar

Learn about the factors influencing skin integrity, identification of clients at risk for pressure ulcers, types of wounds, and the four stages of pressure ulcer development. Explore how to apply the nursing process to patients with skin issues.

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