RNSG 1413 Foundations of Nursing Exam 2 Tarrant County College

Tarrant County College RNSG 1413 Foundations of Nursing Exam 2 1. Explain the factors affecting sleep in adulthood (Perry & Potter, 2017, 998-999) • Physiological, psychological and environmental factors frequently alter the quality and quantity of sleep. Drugs and substances, Lifestyle, usual sleep patterns, emotional stress, environment, exercise and fatigue, food and calorie intake. 2. Describe the interventions to improve sleep (Perry & Potter, 2017, p.1006) • Eliminate distracting noise so the bedroom is quiet as possible, bedtime routines help relax patients in preparation for sleep, comfortable room temp and proper ventilation. Limit caffeine and heavy meals 3 hours before sleep. 3. Describe the staging of a pressure ulcers (Perry & Potter, 2017 p.1187) • Stage 1: Nonblanchable Redness – intact skin, usually over a boney prominence. Discoloration of the skin, warmth, edema, hardness or pain may be present. Harder to identify with dark skinned patients, it may not have visible blanching, but its coloring may differ from the surrounding area. • Stage 2: Partial-Thickness – Loss of dermis presents as a shallow, open ulcer with red-pink wound bed without slough. May present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. • Stage 3: Full Thickness Skin Loss – subcutaneous fat may be visible but bone, tendon and muscle are NOT exposed. May include undermining and tunneling. Varies by anatomical location. Bone/tendon is not visible or directly palpable. • Stage 4: Full Thickness Tissue Loss – exposed bone, tendon, muscle, subcutaneous fat may be visible. Slough or eschar may be present. Undermining and tunneling. Exposed bone/muscle is visible or directly palpable. • Unstageable/Unclassified: Full Thickness Skin or Tissue Loss-Depth Unknown – Actual depth of an ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed is unstageable. Until slough and/or eschar is removed to expose the base of the wound, true depth cannot be determined. Eschar on the heels serves as the “natural cover of the body” and should not be removed. • Suspected Deep-Tissue Injury – Depth Unknown – Purple or maroon localized area of discolored intact skin or a blood filled blister cause by damage of underlying soft tissue from pressure and/or shear. Painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue. May be difficult to detect in dark skinned individuals. • PICTURES AVAILABLE ON PAGE 1188