Tissue Integrity

Question 1

Skin

Answer 1

Largest Organ

Question 2

Skin

Answer 2

Protective Barrier

Question 3

Skin

Answer 3

Nursing responsibility to assess and monitor skin integrity.

Question 4

What is the purpose of the skin?

Answer 4

Protection
Sensory
Vitamin D synthesis
fluid balance
natural flora

Question 5

Epidermis

Answer 5

outer layer

Question 6

dermis

Answer 6

glands, nerve ending

Question 7

subcutaneous tissue

Answer 7

fatty layer

Question 8

What are we looking for in the assessment of the skin?

Answer 8

Especially Bony Prominences
Visual and Tactile
assess any rashes or lesions
Note hair distribution
Skin color
Blanch test

Question 9

Skin Assessment

Answer 9

Assess skin on initiation of care then at least once/shift
High risk patients- assess every 4 hrs or more often

Question 10

Sensory Perception (Completely Limited)

Answer 10

-unresponsive
-limited ability to feel pain over most of the body

Question 11

Sensory Perception (very limited)

Answer 11

-painful stimuli
-cannot communicate discomfort
-sensory impairment over half the body

Question 12

Slightly Limited (sensory perception

Answer 12

Verbal commands
cannot always communicate discomfort.
sensory impairment 1-2 extremities

Question 13

activity (chairfast)

Answer 13

Cannot bear own weight assisted to chair..

Question 14

braden scale: Low risk

Answer 14

15-18
-regular turning schedule
-enable as much activity as possible
-protect heels
-manage moisture friction and sheer

Question 15

Moderate Risk

Answer 15

13-14
position patient at 30 degree lateral incline using wedges or pillows

Question 16

Early intervention protocol CHANT

Answer 16

cleanse
hydrate and protect skin
alleviate pressure
nourish
Treat

Question 17

systemic response to inflammation

Answer 17

Increased WBC count
Malaise
Nasu and anorexia

Question 18

Acute Inflammation

Answer 18

neutrophils predominant cell type at site

Question 19

A good sign of wound healing

Answer 19

granulation tissue