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NUR 205 EXAM 2 Questions with Verified Answers.
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NUR 205 EXAM 2 Questions with Verified Answers.Largest Organ of the body - ANS the Skin
Two layers of the skin - ANS Epidermis and Dermis
Epidermis - ANS top layer of skin
Stratum Cornea - ANS Outermost layer of the epidermis, which consists of flattened,
keratinized cells
Define Pressure Ulcers - ANS Described as impaired skin integrity related to unrelieved,
prolonged pressure, usually over a boney prominence
Pressure Ulcer Risk Factors - ANS -decreased mobility
-decreased sensory perception
-fecal or urinary incontinence
-poor nutrition
Individuals at risk for pressure ulcers - ANS -older adults that have experienced a
trauma
-those with spinal cord injuries
-those who have sustained a fractured hip
-those in long-term homes or community care, the acutely ill
-individuals with diabetes
-patients in critical care settings (ICU)
Dermis - ANS inner layer of skin, provides tensile strength, mechanical support, and
protection for the underlying muscles, bones, and organs
Tissue Ischemia - ANS Pressure applied over a capillary exceeds the normal capillary
pressure, and the vessel is occluded for a prolonged period of time.
Dermal-epidermal junction - ANS separates dermis and epidermis
3 pressure related factors that contribute to pressure ulcer development - ANS -
pressure intensity
-pressure duration
-tissue tolerance
Non-blanch able hyperemia - ANS redness that persists after palpation and indicates
tissue damage
Stage 1 Pressure Ulcer - ANS -intact skin with nonblanchable redness
-warm to touch, edema, can be a hardened area
, Stage 2 Pressure Ulcer - ANS -partial thickness skin loss
-shallow but open
-no slough or drainage
-red/pink wound bed
Stage 3 Pressure ulcer - ANS -full thickness tissue loss with visible underlying fat
-NO bone, muscle or tendon is visible
-can have slough
-undermining/tunneling
Stage 4 Pressure ulcer - ANS -full thickness tissue loss WITH visible muscle, bone or
tendon
-tunneling/undermining
Unsaleable Pressure Ulcer - ANS -Full thickness tissue loss in which the base of the
ulcer is covered by slough (yellow, tan, gray, green or brown) and/or Escher (tan, brown
or black) in the wound bed.
-cannot be measured/depth unknown
Suspected Deep Tissue Injury - ANS -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.
-depth unknown
Primary Wound Healing - ANS -wound that is closed
-surgical incision
-wound that is sutured or stapled
-heals quickly with minimal scar formation
Secondary Wound Healing - ANS -wound edges not approximated
-pressure ulcers, surgical wounds that have tissue loss or contamination
-wounds heal by granulation tissue formation
Tertiary Wound Healing - ANS -wound that is left open to air for several days, then
wound edges are approximated
-wounds that are contaminated and require observation for signs of infection
-closure of wound is delayed until risk of infection is resolved
Acute Wound - ANS -wound that proceeds through an orderly and timely reparative
process
-ex: trauma, surgical incision
-wound edges are clean and intact
Chronic Wound - ANS -wound that fails to proceed through an orderly and timely
process
-ex: vascular compromise, chronic inflammation, or repetitive insults to tissue
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