NSG 501 EXAM 3 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED
Dermal-epidermal junction
Separates dermis and epidermis
Pressure injury
Localized damage to skin and underlying soft tissue
Pressure Injury Pathogenesis
1. Pressure intensity
2. Pressure duration
3. Tissue tolerance: ability of tissue to withstand pressure
Risk factors for pressure injury
Impaired sensory perception
Impaired mobility
Alteration in LOC
Shear (layers of tissue)
Friction (two surfaces)
Moisture
Nutrition
Age
Stage 1 Pressure Injury
,Intact skin with non-blanchable redness
Changes in sensation, temperature, or firmness may precede visual change
Stage 2 Pressure Injury
Partial-thickness skin loss with exposed dermis
Wound bed is viable, pink or red, and moist
Stage 3 Pressure Injury
Full thickness skin loss, adipose tissue visible with epibole (edges rolled up)
Slough or eschar may or may not be visible
Depth of wound depends on location
Stage 4 Pressure Injury
Full thickness skin and tissue loss, with exposed bone, muscle, or tendon
Epibole, undermining, and tunneling often occur
Slough and eschar may be visible
Deep Tissue Pressure Injury
Purple non-blanchable area of intact skin due to deep tissue destruction
Pain and temperature change often precede color change
Unstageable Pressure Injury
, Full-thickness skin and tissue loss, extent of damage cannot be confirmed due to slough
or eschar
Wound base cannot be assessed
Primary Intention (wound healing)
Skin edges approximate or close together during wound healing
Secondary Intention (wound healing)
Skin edges cannot come together due to extensive tissue loss. Healing occurs gradually
(wound contraction with scar formation)
Tertiary Intention
Delayed primary closure -- surgical wounds with deep tissue layers are closed at some
point, fat and skin layers left open
Factors Influencing Wound Healing
Age, scar tissue, nutrition, immunosuppression, obesity, extent of wound, tissue
perfusion, diabetes, peripheral vascular disease, radiation, stress
Partial-Thickness Wound Repair
3 stages:
Inflammatory response, epidermal repair, dermal repair
Full-Thickness Wound Repair
Hemostasis phase (controlling bleeding)
Inflammation phase (control bacteria via WBC)
Proliferative phase (production of new tissue)
Remodeling phase (skin comes back stronger and more firm, can leave scar)
COMPLETE SOLUTIONS VERIFIED
Dermal-epidermal junction
Separates dermis and epidermis
Pressure injury
Localized damage to skin and underlying soft tissue
Pressure Injury Pathogenesis
1. Pressure intensity
2. Pressure duration
3. Tissue tolerance: ability of tissue to withstand pressure
Risk factors for pressure injury
Impaired sensory perception
Impaired mobility
Alteration in LOC
Shear (layers of tissue)
Friction (two surfaces)
Moisture
Nutrition
Age
Stage 1 Pressure Injury
,Intact skin with non-blanchable redness
Changes in sensation, temperature, or firmness may precede visual change
Stage 2 Pressure Injury
Partial-thickness skin loss with exposed dermis
Wound bed is viable, pink or red, and moist
Stage 3 Pressure Injury
Full thickness skin loss, adipose tissue visible with epibole (edges rolled up)
Slough or eschar may or may not be visible
Depth of wound depends on location
Stage 4 Pressure Injury
Full thickness skin and tissue loss, with exposed bone, muscle, or tendon
Epibole, undermining, and tunneling often occur
Slough and eschar may be visible
Deep Tissue Pressure Injury
Purple non-blanchable area of intact skin due to deep tissue destruction
Pain and temperature change often precede color change
Unstageable Pressure Injury
, Full-thickness skin and tissue loss, extent of damage cannot be confirmed due to slough
or eschar
Wound base cannot be assessed
Primary Intention (wound healing)
Skin edges approximate or close together during wound healing
Secondary Intention (wound healing)
Skin edges cannot come together due to extensive tissue loss. Healing occurs gradually
(wound contraction with scar formation)
Tertiary Intention
Delayed primary closure -- surgical wounds with deep tissue layers are closed at some
point, fat and skin layers left open
Factors Influencing Wound Healing
Age, scar tissue, nutrition, immunosuppression, obesity, extent of wound, tissue
perfusion, diabetes, peripheral vascular disease, radiation, stress
Partial-Thickness Wound Repair
3 stages:
Inflammatory response, epidermal repair, dermal repair
Full-Thickness Wound Repair
Hemostasis phase (controlling bleeding)
Inflammation phase (control bacteria via WBC)
Proliferative phase (production of new tissue)
Remodeling phase (skin comes back stronger and more firm, can leave scar)
