Hondros Nursing Nur 150: Exam 2 with complete solution graded A+

Stage 1 pressure ulcer - Intact skin with nonblanchable redness Stage 2 pressure ulcer - Partial loss of dermis. Shallow open ulcer, usually shiny, or dry. Red-pink wound bed without sloughing or bruising. Stage 3 pressure ulcer - Full thickness tissue loss, subcutaneous fat may be visible. Possible undermining and tunneling. Stage 4 pressure ulcer - Full thickness tissue loss with exposed bone, tendon,or muscle. Slough or eschar may be present as well as undermining and tunneling. Unstageable pressure ulcer - Full thickness tissue loss, wound base covered by slough and eschar therefor dull depth cannot be determined. Slough - Fibrous tissue in wound bed that can be yellow, tan, gray, green, or brown. Nursing interventions to prevent pressure unlcers - Reposition bed bound pt every two hours, instruct pt in wheelchair to shift their weight every hour. Use of cushions and barrier cream. Manage moisture, optimize nutrition and hydration. Cognition - All the processes involved in human thought External nutrition - Nutrition support via tube feedings Parenteral nutrition - Nutrition supplied intravenously DRI - Refers to a set of nutritional based values that serve for both assessing and planning dietsThree ways to confirm proper NG placement - Chest x-ray, PH test gastric contents, air bolus. With tube feeding what must be monitored daily - I/O, daily weight, daily labs