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Practice questions for this set
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Terms in this set (94)
three types of nursing diagnoses -risk diagnoses
-problem-focused diagnoses
-health promotion diagnoses
what are the common sources of collecting, clustering, and interpreting data
error in the nursing diagnostic
process?
, related factors associated with a patient's actual or potential
response to a health problem
pressure injury impaired skin integrity related to unrelieved,
prolonged pressure
patients at risk for pressure injuries older adults, recent trauma, spinal cord injuries, hip
fracture, long-term homes or community care,
diabetes mellitus, critical care settings
risk factors for pressure injury impaired sensory perception, impaired mobility,
alteration in level of consciousness, shear, friction,
moisture
stage 1 pressure injury intact skin with a localized area of nonblanchable
erythema, which may appear differently in darkly
pigmented skin
stage 2 pressure injury partial thickness skin loss with exposed dermis
stage 3 pressure injury full thickness skin loss in which adipose tissue,
granulation tissue, and epibole (rolled wound
edges) are normally present. may contain slough or
eschar
stage 4 pressure injury full thickness skin and tissue loss with exposed
fascia, muscle, tendon, ligament, cartilage, or bone.
may contain slough, eschar, epibole, undermining,
and/or tunneling
unstageable pressure injury obscured full-thickness skin and tissue loss