nursing 205 exam 2 hondros | 86 Questions and Answers(A+ Solution guide)
tissue integrity - the ability of body tissues to regenerate and/or repair to maintain normal physiological processes interventions to maintain tissue integrity - reposition turning adequate nutrition skin assessments blanching test - A test of the rate of capillary refill; blanching means to cause to become pale by applying digital pressure. Non-blanchable - skins stay very red even with finger pressure; indicates severe skin injury Stage 1 pressure ulcer - intact skin with nonblanchable redness stage 2 pressure ulcer - partial thickness skin loss involving epidermis, dermis, or both red/pink noist blister et shallow crater stage 3 pressure ulcer - full thickness tissue loss with visible fat stage 4 pressure ulcer - Full-thickness tissue loss with exposed bone, muscle, or tendon debridement - Removal of foreign matter or dead tissue from a wound promotes healing eschar - a thick layer of dead tissue and tissue fluid that develops over a deep burn area Types of drainage - serous, sanguineous, serosanguineous, purulent
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