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NURS 2518 Final Exam Questions And 100% Correct Answers
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NURS 2518 Final Exam Questions And 100%Correct Answers
Age related changes to skin
thinning (more vulnerable to damage) skin looks more transparent and fragile
longer wound healing time
fewer melanocytes - resulting in paler skin, less protection from the sun
melanin synthesis increased in some places - pigment spots
less vascular (cooler, paler skin)
collagen synthesis decreases - loss of elasticity
elastin decreases in quality
sweat glands decrease
sebaceous glands produce less sebum: prevents water loss
diminished perception of sensory nerves: pain, pressure, temp
Tissue integrity related concepts
Tissue integrity scope
subcutaneous tissue changes
layer of fat atrophies in some areas (hands, face, feet) and hypertrophies in other areas
with overall increase of body
nail changes
harder, thicker, slower growth, nails become thinner, fragile, brittle and more prone to
splitting, more opaque
,fungal infection not a result, but common
hair changes
hair loss more common in men
by age 50, 40% of women will experience some form of hair thinning
leg hair lessens/normal absence of leg hair can be misinterpreted as a sign of PVD
skin risk factors
health conditions associated with
- poor peripheral perfusion
- malnutrition or obesity
- dehydration or edema
- impaired mobility
- immunosuppression
exposure to irritants
- radiation, temp extremes, chemical and mechanical trauma, medical treatments
tissue trauma
- friction, shearing, moisture, pressure
tissue integrity
the state of structurally intact and physiologically functioning epithelial tissues such as
the integument (including the skin and subcutaneous tissue) and mucous membranes
tissue integrity impacts on related concepts
,thermoregulation (vasodilation, vasoconstriction and sweating)
elimination (skin damage, dec. waste removal through pores)
fluid and electrolyte balance and loss of hydration
protection from infection
safety (loss of deep sensory tissues)
sensory perception (sensory structure, skin lesions)
body image (rashes, burns)
pressure injury
any lesion caused by unrelieved pressure that results in damage to underlying
tissues.Pressure ulcers usually occur over a bony prominence and are staged to
classify the degree of tissue damage observed
pressure injury prevalence
The prevalence of pressure ulcers is quite high in later life and can vary across the
caregiving location. The frail, the non-ambulatory, and persons with neurological
impairments are at the greatest risk for developing pressure ulcers.The role of the
gerontological nurse is prevention, assessment, and ensuring appropriate treatment
pressure injury common locations
staging pressure ulcers
unstageable pressure injury
, wound bed covered by necrotic tissue/slough/eschar
unable to accurately stage injury
depth unknown
deep tissue pressure injury
▪ A localized area of purple or maroon discoloured intact skin
▪ A blood-filled blister due to damage of underlying soft tissue from pressure &/or shear
▪ An area which is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue
measuring risk for pressure ulcer
WRHA's Pressure Ulcer Prevention, Assessment and Management Algorithm
pressure ulcer collaborative interventions
holistic care: treat whole person
- KEEP PRESSURE OFF
- maximize mobility
- minimize moisture
- reduce friction and shear
- nutritional support
- pharmacotherapy
- surgical interventions
- wound care specialist
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