Exam (elaborations)
NSG 120 (COMPLETE & ACCURATE) FINAL EXAM STUDY GUIDE GUARANTEED PASS
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- NURSING
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NSG 120 (COMPLETE & ACCURATE) FINAL EXAM STUDY GUIDE GUARANTEED PASS
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1NSG 120 (COMPLETE & ACCURATE) FINAL EXAM STUDY GUIDE
GUARANTEED PASS
Skin Integrity
Skin layers
• Epidermis
o Top layer of skin
• Dermis
o Inner layer of skin
o Collagen
• Dermal–epidermal junction
o Separates dermis and epidermis
Nursing Diagnosis
• Risk for infection
• Imbalanced nutrition: less than body requirements
• Acute or chronic pain
• Impaired physical mobility
• Impaired skin integrity
• Risk for impaired skin integrity
• Ineffective peripheral tissue perfusion
• Impaired tissue integrity
Pressure Ulcers
• Result from any unrelieved pressure on the skin, causing underlying tissue
damage pressure, shearing forces, friction, moisture
• Stages:
1) Nonblanchable erythema of intact skin
2) Partial-thickness skin loss involving epidermis or dermis
3) Full-thickness skin loss involving damage or loss of subcutaneous
tissue
4) Full-thickness skin loss with exposure of muscle, bone, or supporting
structures
, 2
• Slough- soft yellow or white tissue is characteristic of slough
• Eschar- black, brown, tan, or necrotic tissue
Risk factors for pressure ulcer development
• Impaired sensory perception
• Impaired mobility
• Alteration in LOC (level of consciousness)
• Shear – when you get somebody off the bed. Use equipment and resources. Do not pull the
patient up, lift the patient.
• Friction
• Moisture- constant moisture will cause skin breakdown.
Preventative Measures
• Early detection
• Frequent skin assessment
• Repositioning
• Pressure reduction, removal, and distribution
• Elimination of moisture
• Adequate nutrition, oxygenation, and fluid balance must be maintained
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
• Skin does not blanch when firmly pressed, has purple discoloration, or has significant color
change.
▪ Reassess frequency of turning schedule.
▪ Implement agency skin-care protocols.
▪ Consider use of pressure-redistribution surface to reduce pressure ulcer risk.
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