NSG-300 Exam 2 COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED
A+||BRAND NEW!!
C
Terms in this set (258)
what places patients at risk for pressure pressure intensity, pressure duration, tissue tolerance,
ulcers/impaired skin integrity 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 infectious exudate
exudate which one would you be most
concerned about
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
complications of wound healing hemorrhage, infection, dehiscence, evisceration
CMS created policy for hospitals to no longer receive additional
reimbursement for care related to eight conditions to improve
quality of health care
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED
A+||BRAND NEW!!
C
Terms in this set (258)
what places patients at risk for pressure pressure intensity, pressure duration, tissue tolerance,
ulcers/impaired skin integrity 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 infectious exudate
exudate which one would you be most
concerned about
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
complications of wound healing hemorrhage, infection, dehiscence, evisceration
CMS created policy for hospitals to no longer receive additional
reimbursement for care related to eight conditions to improve
quality of health care
