NSG-300 Exam 2 Questions And Answers (Verified And Updated)

NSG-300 Exam 2 Questions And Answers (Verified And Updated) what places patients at risk for pressure ulcers/impaired skin integrity - answerpressure intensity, pressure duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in LOC, shear, friction, moisture layers of the skin - answerepidermis, dermis (collagen) body's defenses against infection - answernormal flora, inflammatory response, immune response comprehensive wound assessment - answer-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 - answerassesses 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 - answerskin 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 - answerpartial-thickness loss of dermis; shallow broken skin; red-pink wound bed type 3 ulcers - answerfull-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 - answerfull-thickness tissue loss with exposed bone, muscle, or tendon. possible tunneling and undermining unstageable pressure ulcer - answerbase of ulcer covered by slough and/or eschar in the wound bed so the depth is unknown; exudate; deep tissue injury - answerPurple 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 - answerfrom least to most contaminated eschar - answerblack, brown or necrotic tissue in wound bed; needs to be removed before healing slough - answerstringy 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 - answerinfectious exudate factors influencing heat and cold tolerance - answerExposure time Exposed skin Temperature Age Perception of sensory stimuli assessment for pressure ulcers includes - answerlocation, 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 - answerbecause the wound heals inside-out granulation tissue - answergood, 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? - answerby 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? - answerby 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 - answerwound that is closed/approximated; little tissue loss; low risk of infection; quick healing with no scar usually (surgical incision) secondary intention - answera 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 - answerWound that is left open for several days, then wound edges are approximated; doctor can monitor status of wound complications of wound healing - answerhemorrhage, infection, dehiscence, evisceration CMS - answercreated 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 - answerContaminated 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 - answerprotein (albumin)