NSG-300 Exam 2
what places patients at risk for pressure ulcers/impaired skin integrity - ANS-pressure intensity,
pressure duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in
LOC, shear, friction, moisture
layers of the skin - ANS-epidermis, dermis (collagen)
body's defenses against infection - ANS-normal flora, inflammatory response, immune
response
comprehensive wound assessment - ANS--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 - ANS-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 - ANS-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 - ANS-partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers - ANS-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 - ANS-full-thickness tissue loss with exposed bone, muscle, or tendon. possible
tunneling and undermining
unstageable pressure ulcer - ANS-base of ulcer covered by slough and/or eschar in the wound
bed so the depth is unknown; exudate;
,deep tissue injury - ANS-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 - ANS-from least to most contaminated
eschar - ANS-black, brown or necrotic tissue in wound bed; needs to be removed before
healing
slough - ANS-stringy pale-yellowish tissue that lays in the wound bed; needs to be removed
before healing
if a patient has slough, eschar, and infectious exudate which one would you be most concerned
about - ANS-infectious exudate
factors influencing heat and cold tolerance - ANS-Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - ANS-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 - ANS-because the wound heals inside-out
granulation tissue - ANS-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? - ANS-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? - ANS-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 - ANS-wound that is closed/approximated; little tissue loss; low risk of
infection; quick healing with no scar usually (surgical incision)
secondary intention - ANS-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 - ANS-Wound that is left open for several days, then wound edges are
approximated; doctor can monitor status of wound
complications of wound healing - ANS-hemorrhage, infection, dehiscence, evisceration
CMS - ANS-created policy for hospitals to no longer receive additional reimbursement for care
related to eight conditions to improve quality of health care
signs and symptoms of wound infection - ANS-Contaminated or traumatic wounds: 2-3 days
Post op surgical wound: 4-5 days
Fever, tenderness and pain at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
Dehiscence
Evisceration
what is needed for wound healing - ANS-protein (albumin)
factors influencing pressure ulcer formation and wound healing - ANS--nutrition
-tissue perfusion
-infection
-age
-psychosocial impacts (body image)
when should you give an analgesic - ANS-at least 30 minutes before removing a wound
dressing
Scientific Method nursing - ANS-•identify the problem,
•collect data,
•formulate a question or hypothesis,
what places patients at risk for pressure ulcers/impaired skin integrity - ANS-pressure intensity,
pressure duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in
LOC, shear, friction, moisture
layers of the skin - ANS-epidermis, dermis (collagen)
body's defenses against infection - ANS-normal flora, inflammatory response, immune
response
comprehensive wound assessment - ANS--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 - ANS-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 - ANS-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 - ANS-partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers - ANS-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 - ANS-full-thickness tissue loss with exposed bone, muscle, or tendon. possible
tunneling and undermining
unstageable pressure ulcer - ANS-base of ulcer covered by slough and/or eschar in the wound
bed so the depth is unknown; exudate;
,deep tissue injury - ANS-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 - ANS-from least to most contaminated
eschar - ANS-black, brown or necrotic tissue in wound bed; needs to be removed before
healing
slough - ANS-stringy pale-yellowish tissue that lays in the wound bed; needs to be removed
before healing
if a patient has slough, eschar, and infectious exudate which one would you be most concerned
about - ANS-infectious exudate
factors influencing heat and cold tolerance - ANS-Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - ANS-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 - ANS-because the wound heals inside-out
granulation tissue - ANS-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? - ANS-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? - ANS-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 - ANS-wound that is closed/approximated; little tissue loss; low risk of
infection; quick healing with no scar usually (surgical incision)
secondary intention - ANS-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 - ANS-Wound that is left open for several days, then wound edges are
approximated; doctor can monitor status of wound
complications of wound healing - ANS-hemorrhage, infection, dehiscence, evisceration
CMS - ANS-created policy for hospitals to no longer receive additional reimbursement for care
related to eight conditions to improve quality of health care
signs and symptoms of wound infection - ANS-Contaminated or traumatic wounds: 2-3 days
Post op surgical wound: 4-5 days
Fever, tenderness and pain at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
Dehiscence
Evisceration
what is needed for wound healing - ANS-protein (albumin)
factors influencing pressure ulcer formation and wound healing - ANS--nutrition
-tissue perfusion
-infection
-age
-psychosocial impacts (body image)
when should you give an analgesic - ANS-at least 30 minutes before removing a wound
dressing
Scientific Method nursing - ANS-•identify the problem,
•collect data,
•formulate a question or hypothesis,
