Core Concepts Exam 4

Core Concepts Exam 4
5 factors affecting skin integrity
- genetics & heredity
- age
- chronic illness & treatment
- medications
- poor nutrition


3 risk assessment tools for pressure ulcers
- Braden scale
- Norton scale
- Waterlow scale


Anything less than ___ on the Braden scale is a high risk for a pressure injury
18


Anything greater than ___ on the Braden scale is a low risk for a pressure injury
19


The Braden scale has a possibility of ___ possible points
23


Nonblanchable erythema signaling potential ulceration
Stage I


Partial-thickness skin loss involving epidermis and possibly dermis
Stage II


Full-thickness skin loss involving damage or necrosis of subcutaneous tissue
Stage III


Full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures
Stage IV


3 types of wound healing
- primary
- secondary
- tertiary


___ healing occurs when there's little to no tissue loss
primary


___ healing occurs when there is a loss of tissue; longer healing time
secondary

, ___ healing occurs when there's a deep open wound left open to close later
tertiary


3 phases of wound healing
- inflammatory
- proliferative
- maturation


4 types of wound exudate
- serous
- purulent
- sanguinous
- mixed


Clear fluid
serous


Mixture of clear & blood (pink)
serosanguinous


Bright red blood
sanguinous


Yellow, thick drainage
purulent


___ exudate is indicative of infection
purulent


4 complications of wound healing
- hemorrhage
- infection
- dehiscence
- evisceration


___ open wounds are healthy regeneration of tissue; must protect
red


___ open wounds indicate the presence of purulent drainage and slough; must cleanse
yellow


___ open wounds indicate the presence of eschar that hinders healing and requires removal; must
debride
black