NUR 205: Transition to Associate Degree Nursing (Winter 2021)

Week 5: Pre-Class Assignment

Assessment/Tissue Integrity
Pre-Class Assignment

*Pre-class assignments are expected to be completed and uploaded in CAMS prior to

class. *As always, be prepared to discuss your homework in class.

1. *Define tissue integrity in your own words.

Damaged skin in the dermis, epidermis, and hypodermis (subcutaneous layer).

2. Explain the nursing responsibility for maintaining the tissue integrity of patients?
The nurse is responsible for assessing, providing hygiene, wound care, medication
administration and patient teaching when it comes to care of the patient skin.

3. Provide age related differences, assessments and interventions in the boxes below.
Age-related differences in skin integrity:
Adults:
 Sun- environment damage
 Thinker skin
 Pain perception normal
 Skin health moisturizers elasticity and
strength
Assessment and nursing interventions
needed in RN role:
 Assess for abnormal discoloration,
lesions bumps and redness.
 Healthy History
 Skin is consistent in color.
 Smooth skin normal

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 NUR 205: Transition to Associate Degree Nursing (Winter 2021)
Week 5: Pre-Class Assignment

3. *Identify and explain what type of clinical conditions impact tissue integrity and what
nursing interventions or measures will the RN take to prevent patients from acquiring
these conditions?
The type of clinical conditions impact tissue integrity is psoriasis, Cellulitis, Tinea Pedis,
Sunburn and malignant melanoma. Psoriasis is recurrent inflammation of the skin that
can lead to mil silvery scales to extensive lesions. Cellulitis is the inflammation of the skin
of the subcutaneous layer caused by streptococcal infection. Tinea Pedis is caused by fungal
infection between the toes and blisters in plantar surface.
RN can prevent these conditions by educating patients the importance of sunblock and reducing
excessive exposure to the sun. Also prevention of fungal infection in the locker room and
checking the skin for skin discoloration.

4. Identify age-related and individual risk factors for the development of skin disruptions
for the adult.
Most risk factors are environmental and sun damage over time. Skin can appear leathery and
wrinkled over time due to excessive exposure to the sun; worse case scenario cancer may
occur. Tears are easily acquired in the skin if skin is too thin and fragile.

5. Define how nutritional factors play a role at putting patients at risk for skin
breakdown.
Without adequate nutrition skin can become flaky and dry. Hair may become dull and the
subcutaneous fat can disappear. If epithelial skin tissue does not get enough nutrients chances
of damage and delayed healing increases.

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 NUR 205: Transition to Associate Degree Nursing (Winter 2021)
Week 5: Pre-Class Assignment

6. Give an example of primary and secondary prevention/care related to tissue integrity

management and how collaborative intervention is involved.

Primary: prevents disrupted tissue integrity. This includes nutrition, hygiene and protection from
sun exposure and environmental hazards.

Secondary: This is screening. This also educates the patient of what to look for in skin spy early
detection of malignant melanoma. This can be used by monic ABCDEF (A is asymmetry, B
boarder that is irregular etc.)

Tertiary: Are collaborative intervention. These are Pharmacotherapy (antibiotics, steroid), wound
care, photo therapy and surgical procedures.

Tissue Integrity
There are six major categories of impaired tissue integrity. List each category and an example
of each.
1.Trauma/Injury- deep wound penetration.
2.Loss of perfusion- loss of digits
3.Immunological reactions- allergies to soaps
4.Infections and infestations- Bacteria and fungal infections in the skin
5.Thermal or radiation injury- Exposure to excessive UV radiation while sunbathing.
6.Lesions- Benign shin growth

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 NUR 205: Transition to Associate Degree Nursing (Winter 2021)
Week 5: Pre-Class Assignment

Draw the concept map from Giddens, Page 268, Figure: 26-3. For each of the concepts,
add a cause and/or effect for each one.

Nutrition Absence of this will suffocate tissue.

Perfusion Oxygen and nutrients enriched blood
Gas exchange Oxygen from blood diffusing to epithelial and
connective cell.
Elimination Skin contacts with caustic excretion.
Thermoregulation Sweating is used to cool the body.
Fluid and electrolytes Sweating is used to cool the body.
Infection Break in skin barrier leads to infection of
environmental organism.
Pain Skin contains many sensory nerve endings
that react to irritation.
Sensory perception Prevents prolonged pressure.
mobility Have body move away from stimulus and
pressure.

Nutrition/Malnutrition
In your own words, explain the interrelationship between nutritional status and health status.
(5 lines or more.)
Nutrition status and health status are important in interrelationship because they can not have
one without the other. Health status will be effective whether the person has excessive nutrition
or insufficient nutrition. Malnutrition causes tissues to suffocate and possibly atrophy. Excessive
nutrition especially with high calorie nutrient can cause obesity. Obesity can cause heart
disease or may lead to cancer.

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 NUR 205: Transition to Associate Degree Nursing (Winter 2021)
Week 5: Pre-Class Assignment

Review the clinical exemplars related to nutrition in Giddens, pages 151-152. Using the
concept map in Potter & Perry, page 1117, Figure 45-5, apply critical thinking, and write a
priority assessment, diagnosis and intervention for each exemplar. Use your Potter &
Perry, Silvestri and NCSBN test plan as references.

Protein calorie malnutrition:

Nursing diagnosis: Imbalance nutrition less than the body requirement
Priority Assessment: Diet history, medical history, and nutrition screening.
Intervention: Teach dietary guidelines to adults and encourage protein diet.

Anorexia Nervosa
Nursing Diagnosis: Imbalance nutrition less than the body requirement.
Priority Assessment: Diet history, Medical history, and nutritional screening.
Intervention: Teach Dietary guidelines to patients and refer patients to psychological help with
counselors. Use calm active listening and reassurance.

Celiac Disease
Nursing Diagnosis: Imbalance nutrition less than the body requirement
Priority Assessment: Diet history, Medical history, and nutritional screening
Intervention: Instruct patient to truck calorie, teach dietary guidelines to adult, educate about the
disease, teach food brands available without gluten.

Obesity
Nursing Diagnosis: Obesity
Priority Assessment: Diet history, Medical history, and nutritional screening.
Intervention: Instruct patient to truck calorie intake and teach dietary guidelines.

Hyperlipidemia
Nurse Diagnosis: Overweight/ Risk for overweight
Priority Assessment: Diet history, Medical history, and nutritional screening.
Intervention: Instruct patient to truck calorie intake and teach dietary guidelines.

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NUR 205: Transition to Associate Degree Nursing (Winter 2021)
Week 5: Pre-Class Assignment

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