NURC-1104 Final Exam 1 Questions And
All Correct Answers.
Pressure Injuries: Risk Factors - Answer - Impaired sensory perception
- Impaired mobility
- Alteration in LOC
- Shear
- Friction
- Moisture
Pressure Injuries: Classification - Answer - Stage 1: Non-blanchable erythema of intact skin
- Stage 2: Partial-thickness skin loss with exposed dermis; partial loss of skin layers
- Stage 3: Full-thickness skin loss; go into subcutaneous tissue and into deep layers depending on
location of wound
- Stage 4: Pressure Injury: Full-thickness skin and tissue loss; go into subcutaneous tissue and into deep
layers depending on location of wound
- Unstageable
Misc. Wound Info - Answer - Granulation tissue: new, progression to healing
- Slough: usually yellow, stringy and is attached to wound bed- needs removed, for healing
- Eschar: necrotic, needs removed for healing
- Size of wound: Length, depth, width (if wound is like a pressure injury, if it is primary - just need length)
- Exudate: COCA (color, odor, consistency, amount) and skin around the wound called periwound
- Periwound: Examine redness, warmth, signs of maceration
Healing by Primary Intention - Answer - Well approximated; risk infection low
- Incision edges of a clean surgical incision remain closed
- Tissue loss is minimal and skin quickly regenerates
,Healing by Secondary Intention - Answer - Involves loss of tissue
- Wound edges not approximated
- Heals by granulation tissue
- Wound contraction and epithelialization (greatest risk for infection)
- Examples: burn, some pressure injuries; infection is greater
Device Related Pressure Injuries - Answer - Feeding tubes; oxygenation tubes
- IV catheters; foly catheters
- Orthopedic devices
- Restraints
- Negative pressure wound therapy
- Bedpans
- Abdominal binders
- ID bands
- Braces
- Casts
Partial-Thickness Wound Repair - Answer - Inflammatory response
- Epithelial proliferation and migration
- Reestablishment of the epidermal layers
Full-thickness Wound Repair - Answer - Hemostasis: Clots form
- Inflammatory: Can be good, if prolonged like with cancer or infection it's not good
- Proliferative: Wound fills with granulation tissue
- Maturation: Collagen fills in wound; develops scar tissue; final stage of healing; can take a long time
depending on extent of wound
Complications of Wound Healing - Answer - Hemorrhage: External or internal
- Infection: Microorganisms invade tissue
, - Dehiscence: Separation of wound
- Evisceration: TOTAL separation of wound (emergency)
Factors influencing pressure injury formation and wound healing - Answer - Nutrition
- Tissue perfusion
- Infection
- Age
- Psychosocial impact of wounds
- Poor circulation
- Other disease processes
Skin Tears - Answer - Upper and lower extremities most common sites
- 80% occur on arms and hands
- Caused by friction and shearing
- Painful and can lead to wound complications
- Most frequently in elderly due to skin changes in elastic fibers in dermis, increased fragility of blood
vessels, changes in the membrane between epidermis and dermis, and thickening of collagen; These
changes cause skin to age and skin appears translucent, wrinkled, thin, dry, fragile and lacking tensile
strength.
Skin Tear Prevention - Answer - Careful and safe moving
- Pad wheelchairs and bed rails
- Keep nails short(patient and health care provider)
- Do not wear jewelry
- Use long sleeves
- Wear long sleeves (patient and health care provider
- Carefully dress and undress patient
- Provide good lighting
- Provide safe area
- Skin protectors
All Correct Answers.
Pressure Injuries: Risk Factors - Answer - Impaired sensory perception
- Impaired mobility
- Alteration in LOC
- Shear
- Friction
- Moisture
Pressure Injuries: Classification - Answer - Stage 1: Non-blanchable erythema of intact skin
- Stage 2: Partial-thickness skin loss with exposed dermis; partial loss of skin layers
- Stage 3: Full-thickness skin loss; go into subcutaneous tissue and into deep layers depending on
location of wound
- Stage 4: Pressure Injury: Full-thickness skin and tissue loss; go into subcutaneous tissue and into deep
layers depending on location of wound
- Unstageable
Misc. Wound Info - Answer - Granulation tissue: new, progression to healing
- Slough: usually yellow, stringy and is attached to wound bed- needs removed, for healing
- Eschar: necrotic, needs removed for healing
- Size of wound: Length, depth, width (if wound is like a pressure injury, if it is primary - just need length)
- Exudate: COCA (color, odor, consistency, amount) and skin around the wound called periwound
- Periwound: Examine redness, warmth, signs of maceration
Healing by Primary Intention - Answer - Well approximated; risk infection low
- Incision edges of a clean surgical incision remain closed
- Tissue loss is minimal and skin quickly regenerates
,Healing by Secondary Intention - Answer - Involves loss of tissue
- Wound edges not approximated
- Heals by granulation tissue
- Wound contraction and epithelialization (greatest risk for infection)
- Examples: burn, some pressure injuries; infection is greater
Device Related Pressure Injuries - Answer - Feeding tubes; oxygenation tubes
- IV catheters; foly catheters
- Orthopedic devices
- Restraints
- Negative pressure wound therapy
- Bedpans
- Abdominal binders
- ID bands
- Braces
- Casts
Partial-Thickness Wound Repair - Answer - Inflammatory response
- Epithelial proliferation and migration
- Reestablishment of the epidermal layers
Full-thickness Wound Repair - Answer - Hemostasis: Clots form
- Inflammatory: Can be good, if prolonged like with cancer or infection it's not good
- Proliferative: Wound fills with granulation tissue
- Maturation: Collagen fills in wound; develops scar tissue; final stage of healing; can take a long time
depending on extent of wound
Complications of Wound Healing - Answer - Hemorrhage: External or internal
- Infection: Microorganisms invade tissue
, - Dehiscence: Separation of wound
- Evisceration: TOTAL separation of wound (emergency)
Factors influencing pressure injury formation and wound healing - Answer - Nutrition
- Tissue perfusion
- Infection
- Age
- Psychosocial impact of wounds
- Poor circulation
- Other disease processes
Skin Tears - Answer - Upper and lower extremities most common sites
- 80% occur on arms and hands
- Caused by friction and shearing
- Painful and can lead to wound complications
- Most frequently in elderly due to skin changes in elastic fibers in dermis, increased fragility of blood
vessels, changes in the membrane between epidermis and dermis, and thickening of collagen; These
changes cause skin to age and skin appears translucent, wrinkled, thin, dry, fragile and lacking tensile
strength.
Skin Tear Prevention - Answer - Careful and safe moving
- Pad wheelchairs and bed rails
- Keep nails short(patient and health care provider)
- Do not wear jewelry
- Use long sleeves
- Wear long sleeves (patient and health care provider
- Carefully dress and undress patient
- Provide good lighting
- Provide safe area
- Skin protectors
