Nur 150 Final Hondros Questions With Complete Solutions
Blanchable
Press down on the skin, if it turns white, it is "blanchable" (not a
pressure ulcer).
Non-Blanchable
Press down on the skin, if it does not turn white, or "blanch" (is
a stage one
ulcer"
Slough
Fibrous tissue in wound bed that can be yellow, tan, gray, green,
or brown.
Shearing force
occurs when the tissue layers of skin slide on each other, causing
subcutaneous blood vessels to kink or stretch resulting in an
interruption of blood flow to the skin.
Friction
the rubbing of skin against another surface produces what
Skin tears
Traumatic wound resulting from separation of the epidermis
from the dermis. For prevention, proper positioning, turning,
lifting/transferring to prevent friction/shearing.
Cold Therapy
,Helps treat inflammatory responses- decreasing edema, muscle
spasms, pain, and decreasing blood flow to the area.
Important things to know about the application of cold therapy.
Recommended for the first 24-48 hours after injury.
When using a cooling device, you should you leave a cooling
device in place for 15 to 20 minutes
Record; type of cooling device used, location, duration, and
patient's response. Also document any patient teaching and
patient's response to teaching.
It is the PN's responsibility to evaluate proper application, any
adverse signs and symptoms, and patient's response to treatment
for patient's safety
Safety measures for heat and cold.
Do not apply to red or blue areas.
Check condition of skin every 5 minutes when using electrical
cooling device.
What are common symptoms when using an electrical cooling
device
numbness and tingling
Some adverse skin reactions when using a cooling device is
mottling, redness, burning, blistering and numbness.
Important things to know about the application of heat therapy.
You should leave the heating device in place 20 to 30 minutes or
as prescribed.
Preset temp. at 40 degrees Celsius (104F).
Only the PN (not STNA) can assess skin areas prior to
, applications and assess for risks.
Monitor skin condition every 5 minutes.
Record; type of cooling device used, location, duration, and
patient's response. Also document any patient teaching and
patient's response to teaching.
Stage One
Skin is intact, reddened, and non-blanchable.
Stage Two
Partial thickness skin loss with serous drainage
Stage Three
Full thickness skin loss down to the subQ layer.
Stage Four
Full thickness skin loss down to the muscle and bone.
What is in the KATZ Scale (ADL's)
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
Scoring KATZ Scale
Score of 6- indicates full function
Score of 4-indicates moderate impairment
Blanchable
Press down on the skin, if it turns white, it is "blanchable" (not a
pressure ulcer).
Non-Blanchable
Press down on the skin, if it does not turn white, or "blanch" (is
a stage one
ulcer"
Slough
Fibrous tissue in wound bed that can be yellow, tan, gray, green,
or brown.
Shearing force
occurs when the tissue layers of skin slide on each other, causing
subcutaneous blood vessels to kink or stretch resulting in an
interruption of blood flow to the skin.
Friction
the rubbing of skin against another surface produces what
Skin tears
Traumatic wound resulting from separation of the epidermis
from the dermis. For prevention, proper positioning, turning,
lifting/transferring to prevent friction/shearing.
Cold Therapy
,Helps treat inflammatory responses- decreasing edema, muscle
spasms, pain, and decreasing blood flow to the area.
Important things to know about the application of cold therapy.
Recommended for the first 24-48 hours after injury.
When using a cooling device, you should you leave a cooling
device in place for 15 to 20 minutes
Record; type of cooling device used, location, duration, and
patient's response. Also document any patient teaching and
patient's response to teaching.
It is the PN's responsibility to evaluate proper application, any
adverse signs and symptoms, and patient's response to treatment
for patient's safety
Safety measures for heat and cold.
Do not apply to red or blue areas.
Check condition of skin every 5 minutes when using electrical
cooling device.
What are common symptoms when using an electrical cooling
device
numbness and tingling
Some adverse skin reactions when using a cooling device is
mottling, redness, burning, blistering and numbness.
Important things to know about the application of heat therapy.
You should leave the heating device in place 20 to 30 minutes or
as prescribed.
Preset temp. at 40 degrees Celsius (104F).
Only the PN (not STNA) can assess skin areas prior to
, applications and assess for risks.
Monitor skin condition every 5 minutes.
Record; type of cooling device used, location, duration, and
patient's response. Also document any patient teaching and
patient's response to teaching.
Stage One
Skin is intact, reddened, and non-blanchable.
Stage Two
Partial thickness skin loss with serous drainage
Stage Three
Full thickness skin loss down to the subQ layer.
Stage Four
Full thickness skin loss down to the muscle and bone.
What is in the KATZ Scale (ADL's)
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
Scoring KATZ Scale
Score of 6- indicates full function
Score of 4-indicates moderate impairment
