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Exam #5
Chapters 19, 23, 32, & 37
| Question | Answer |
|---|---|
| What should nurses always encourage patients to do? | function at their highest level of independence |
| What are the four main functions of the skin? | protection, sensation, temperature regulation, and excretion/secretion |
| What does the skin protect the body from? | bacteria & other invading organisms protects tissues from thermal, chemical, and mechanical injury |
| What is the function of the sebaceous glands? | secrete sebum - which helps make skin waterproof by preventing water loss from underlying tissues & prevents too much water absorption during bathing/swimming |
| What is the function of Melanin? | absorbs light and protects against ultraviolet rays -skin makes vitamin D when exposed to ultraviolet light (vitamin D is needed to absorb phosphorous and calcium) |
| The skin has sensory organs for: | touch, pain, heat, cold, & pressure |
| How does the skin regulate temperature? | -dilating and constricting blood vessels -activating or inactivating sweat glands |
| What are the functions of sweat glands? | -aids in maintenance of homeostasis of fluid/electrolytes -serve as excretory organs -sweat glands in axillae & external genitalia also secrete fatty acids & proteins |
| What is the function of sebum? | lubricates skin & hair - keeps them softer & pliable -decreases the amount of heat loss & bacteria growth |
| What are the functions of mucous membranes? | -protects against bacterial invasion -secrete mucus -absorb fluid/electrolytes |
| What changes in the integumentary system occur with aging? (1) | -loss of elastic fibers/adipose tissue -thin/transparent skin -loss of collagen fibers - skin fragile/slower to heal -decreased sebaceous glands - dry/itchy skin - altered temp control, results in cold intolerance & higher risk of heat exhaustion |
| What changes in the integumentary system occur with aging? (2) | -decrease in number of hair follicles - thin, slower to grow hair -loss of melanocytes at follies - hair loses color -decrease in nail growth - nails thicken |
| When is the best time to perform a physical assessment? | During bath |
| What variables affect hygiene practice? | economics, ability to perform self-care, personal preference, sociocultural background, patient's mental/physical condition |
| When assessing the patient, it is important to assess ability to perform self-care by assessing what? | cognitive and physical function |
| What can you use to assess for stage I pressure injuries in patients with darkly pigmented skin? | natural light/halogen lamp to look for color changes (may have purple hues) -damaged skin may be boggy/stiff, warmer/cooler -moistening skin |
| What are contributing factors to risk of pressure injury? | -dehydration -obesity -edema |
| What are the major risk factors for pressure injury? | -immobility -inactivity -moisture -malnutrition -advanced age -altered sensory perception -lowered mental awareness -friction/shear |
| What is commonly used to asses pressure injury risk? | Braden Scale for Predicting Pressure Sore Risk |
| After the initial skin assessment for pressure injuries, when should it be repeated? | every 24 hours |
| Why is it so important to document pressure injuries upon arrival, & continue preventing them in relation to Medicare? | will not reimburse "reasonably preventable" pressure injuries -must document pressure injuries upon admission thoroughly/accurately -treatment for stage 3 or 4 pressure injuries will be reimbursed at a higher rate if documented w/in 2 days of admission |
Created by:
ahoyyitbeaddi
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