Tarrant County College
RNSG 1413 Foundations of Nursing
Exam 2
1. Explain the factors affecting sleep in adulthood (Perry & Potter, 2017, 998-999)
• Physiological, psychological and environmental factors frequently alter the
quality and quantity of sleep. Drugs and substances, Lifestyle, usual sleep
patterns, emotional stress, environment, exercise and fatigue, food and
calorie intake.
2. Describe the interventions to improve sleep (Perry & Potter, 2017, p.1006)
• Eliminate distracting noise so the bedroom is quiet as possible, bedtime
routines help relax patients in preparation for sleep, comfortable room temp
and proper ventilation. Limit caffeine and heavy meals 3 hours before sleep.
3. Describe the staging of a pressure ulcers (Perry & Potter, 2017 p.1187)
• Stage 1: Nonblanchable Redness – intact skin, usually over a boney
prominence. Discoloration of the skin, warmth, edema, hardness or pain may
be present. Harder to identify with dark skinned patients, it may not have
visible blanching, but its coloring may differ from the surrounding area.
• Stage 2: Partial-Thickness – Loss of dermis presents as a shallow, open ulcer
with red-pink wound bed without slough. May present as an intact or
, open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer
without slough or bruising.
• Stage 3: Full Thickness Skin Loss – subcutaneous fat may be visible but bone,
tendon and muscle are NOT exposed. May include undermining and tunneling.
Varies by anatomical location. Bone/tendon is not visible or directly palpable.
• Stage 4: Full Thickness Tissue Loss – exposed bone, tendon, muscle,
subcutaneous fat may be visible. Slough or eschar may be present.
Undermining and tunneling. Exposed bone/muscle is visible or directly
palpable.
• Unstageable/Unclassified: Full Thickness Skin or Tissue Loss-Depth Unknown –
Actual depth of an ulcer is completely obscured by slough (yellow, tan, gray,
green or brown) and/or eschar (tan, brown or black) in the wound bed is
unstageable. Until slough and/or eschar is removed to expose the base of the
wound, true depth cannot be determined. Eschar on the heels serves as the
“natural cover of the body” and should not be removed.
• Suspected Deep-Tissue Injury – Depth Unknown – Purple or maroon localized
area of discolored intact skin or a blood filled blister cause by damage of
underlying soft tissue from pressure and/or shear. Painful, firm, mushy,
boggy, warmer or cooler compared to adjacent tissue. May be difficult to
detect in dark skinned individuals.
• PICTURES AVAILABLE ON PAGE 1188
,4. Explain the factors that increase wound healing (Perry & Potter, 2017, p. 1195)
• Nutrition – Calories provide the energy source needed to support the cellular
activity of wound healing. Protein needs are especially increased.
• Tissue Perfusion – Oxygen fuels the cellular functions essential to the healing
process. Patients with peripheral vascular disease are at risk for poor tissue
perfusion because of poor circulation.
• Infection – Wound infection prolongs the inflammatory phases and leads to
additional tissue destruction. Indications of an infection include purulent
drainage, change in odor, volume, redness in surrounding tissue, fever or pain.
• Age – Increased age affects all phases of wound healing. Decrease in functioning
of the macrophage, leads to delayed inflammatory response, delayed collagen
synthesis and slower epithelialization.
• Psychosocial Impact of wounds – Body image changes often impose a great
stress on a patients adaptive mechanisms. Also influence self-concept and
sexuality. Factors that affect patients perception of a wound include the
presence of scars, stitches, drains, odor from drainage, and temporary or
permanent prosthetic devices.
5. Explain the factors that decrease wound healing (Perry & Potter, 2017, p. 1195)
• LOOK AT ANSWER 4.
6. Explain the indications for wound debridement (Perry & Potter, 2017, p. 1206)
, • Debridement is the removal of nonviable, necrotic tissue. Removal of necrotic
tissue is necessary to rid the wound of a source of infection, enable
visualization of the wound bed, and provide a clean base necessary for
healing.
7. What are the characteristics of a healing wound (Perry & Potter, 2017, p. 1191)
• There are three different healing processes.
• Primary Intention (wound that is closed like one that’s sutured or stapled.
Healing occurs by epithelialization; heals quicky with minimal scar formation.
• Secondary Intention (wound is not approximated) heals by granulation tissue
formation, wound contraction and epithelialization. Basically, wound fills up
with scar tissue.
• Tertiary Intention (wound that is left open for several days then edges are
approximated) this is for wounds that are contaminated and require
observation for signs of inflammation.
• Partial thickness wounds heal by regeneration; and a full thickness wound
heals by forming new tissue
8. What are the characteristics of a non-healing wound (Perry & Potter, 2017, p. 1191)
• Infection, hemorrhage (bleeding from wound site), dehiscense (when incision
fails to heal properly, layers of skin and tissue separate) obese patients have a
