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NSG 300 Exam 2 | Questions And Answers Latest {} A+ Graded | 100% Verified
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NSG 300 Exam 2 | Questions And Answers Latest {} A+ Graded | 100% Verified
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NSG 300 Exam 2 | Questions And Answers Latest {2024- 2025} A+ Graded |100% Verified
what places patients at risk for pressure ulcers/impaired skin integrity - pressure intensity, pressure
duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in LOC, shear,
friction, moisture
layers of the skin - epidermis, dermis (collagen)
body's defenses against infection - normal flora, inflammatory response, immune response
comprehensive wound assessment - -ongoing assessment from time of injury, wound care, any
condition changes, and on scheduled basis
-Important to include cause of injury, history of wound, treatment, description, response to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - assesses risk for developing pressure ulcers; includes patient's sensory perception,
moisture, activity, mobility, nutrition, friction and shear; the lower the number the higher the risk
>9= very high risk
10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
type 1 ulcers - skin is intact but may be red or pink and warm to the touch; no blanching
-for POC, there may be no noticeable blanching but skin color may vary
type 2 ulcers - partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers - full-thickness tissue loss with visible fat (subcutaneous layer); pale-yellow color; may
include slough but does not obstruct view of depth of injury
,type 4 ulcers - full-thickness tissue loss with exposed bone, muscle, or tendon. possible tunneling and
undermining
unstageable pressure ulcer - base of ulcer covered by slough and/or eschar in the wound bed so the
depth is unknown; exudate;
deep tissue injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to
damage of underlying soft tissue from pressure and/or shear.
how should you clean a wound - from least to most contaminated
eschar - black, brown or necrotic tissue in wound bed; needs to be removed before healing
slough - stringy pale-yellowish tissue that lays in the wound bed; needs to be removed before healing
if a patient has slough, eschar, and infectious exudate which one would you be most concerned about -
infectious exudate
factors influencing heat and cold tolerance - Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - location, staging (depth), type and % of tissue in wound bed,
wound dimensions (including tunneling), exudate description (if odor is present), and condition of
surrounding skin
why is depth of an ulcer important - because the wound heals inside-out
, granulation tissue - good, fresh tissue that forms during the healing of a wound (wound bed will be red,
moist, and shiny)
How does a partial thickness wound heal? - by regeneration (scratch or abrasion)
-inflammatory response: redness/swelling to area with moderate serous exudate. 1st 24hrs after
wounding.
-epithelial proliferation (reproduction): starts at wound edges and epidermal cells lining appendages
(quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist environment. in dry wound, the cells move
down into a moist level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal thickness and appear as dry, pink
tissue
How does a full thickness wound heal? - by forming new tissue/scar formation, which takes longer
(pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop bleeding
-inflammation: damaged tissue and mast cells secrete histamine (vasodilation of surrounding capillaries
and movement of serum and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation tissue), the area is filled with replacement
tissue (collagen, contraction, and granulation tissue), and the surface is repaired (epithelialization)
-maturation: The collagen scar continues to reorganize and gain strength for several months. Collagen
fibers undergo remodeling or reorganization before assuming their normal appearance
primary intention - wound that is closed/approximated; little tissue loss; low risk of infection; quick
healing with no scar usually (surgical incision)
secondary intention - a wound with loss of tissue; wound is not approximated; have to heal from the
inside-out; if scarring is severe, loss of tissue function may be permanent (pressure ulcers, surgical
wound that has tissue loss)
tertiary intention - Wound that is left open for several days, then wound edges are approximated;
doctor can monitor status of wound
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