Foundations of Nursing Spring 2020 Exam 2 Study Guide

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 4. Explain the factors that increase wound healing (Perry & Potter, 2017, p. 1195)  Nutrition – Calories provide the energy source needed to support the cellular activity of wound healing. Protein needs are especially increased.  Tissue Perfusion – Oxygen fuels the cellular functions essential to the healing process. Patients with peripheral vascular disease are at risk for poor tissue perfusion because of poor circulation.  Infection – Wound infection prolongs the inflammatory phases and leads to additional tissue destruction. Indications of an infection include purulent drainage, change in odor, volume, redness in surrounding tissue, fever or pain.  Age – Increased age affects all phases of wound healing. Decrease in functioning of the macrophage, leads to delayed inflammatory response, delayed collagen synthesis and slower epithelialization.  Psychosocial Impact of wounds – Body image changes often impose a great stress on a patients adaptive mechanisms. Also influence self-concept and sexuality. Factors that affect patients perception of a wound include the presence of scars, stitches, drains, odor from drainage, and temporary or permanent prosthetic devices. 5. Explain the factors that decrease wound healing (Perry & Potter, 2017, p. 1195)  LOOK AT ANSWER 4. 6. Explain the indications for wound debridement (Perry & Potter, 2017, p. 1206)  Debridement is the removal of nonviable, necrotic tissue. Removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing. 7. What are the characteristics of a healing wound (Perry & Potter, 2017, p. 1191)  There are three different healing processes.  Primary Intention (wound that is closed like one that’s sutured or stapled. Healing occurs by epithelialization; heals quicky with minimal scar formation.  Secondary Intention (wound is not approximated) heals by granulation tissue formation, wound contraction and epithelialization. Basically, wound fills up with scar tissue.  Tertiary Intention (wound that is left open for several days then edges are approximated) this is for wounds that are contaminated and require observation for signs of inflammation.  Partial thickness wounds heal by regeneration; and a full thickness wound heals by forming new tissue