NUR 155 Exam 3 Exam Three Study Guide With Complete Solutions

NUR 155 Exam 3

Exam Three Study Guide With Complete Solutions

Wounds

•              Factors Affecting Skin Integrity

o   Genetics and heredity

o   Age

o   Chronic illness and their treatments

o   Medications - antibiotics, decreased immune system drugs, steroids (increase BP), and people with a sugary base, like diabetics, tend to have an increased risk of infection

o   Poor nutrition

Types of Wounds

o   Wounds are either Intentional or unintentional

▪     Intentional

•         Trauma that occurs during therapy

•         Example: operations or venipunctures

▪     Unintentional

•         Accidental

•         Example: a person may fracture an arm in an automobile collision

o   Classifying wounds by Depth

▪         Partial thickness: confined to the skin, that is, the dermis and epidermis; heal by regeneration

▪     Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly

muscle and bone; require connective tissue repair

o   Wounds contamination

▪         Clean wounds: infected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital and urinary tracts are not entered. Clean wounds are primarily closed wounds.

▪         Clean-contaminated wounds: surgical wounds in which the respiratory, gastrointestinal, genital or urinary tract has been entered. Such wounds show no evidence of inflammation.

▪         Contaminated wounds: include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Contaminated wounds show evidence of inflammation.

▪         Dirty or infected wounds: include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.

o   Types of Wounds

▪     Incision

•         Cause: sharp instrument (ex: knife/scalpel) – surgical/cut

•         Open wound; deep or shallow; once the edges have been sealed together as a part of treatment or healing, the incision becomes a closed wound