FPCC Exam Latest 2024/25|Questions
and answers/Complete Solutions
pressure ulcer nursing assessment: where - ✔bony prominences
areas under weight
medical appliances
damp areas
intertriginous
pressure ulcer nursing assessment: what? - ✔color of skin: blanching or no
warmth
edema
change in tissue consistency
REASSESS ABNORMAL FINDINGS IN ONE HOUR
pressure ulcer nursing assessment: when? - ✔on
admission daily
as needed based on assessment findings (reasses abnormal findings within one hour)
pressure ulcer nursing assessment who? - ✔registered nurse. do not delegate
pressure ulcer nursing assessment: how? - ✔braden scale
stage I pressure ulcer - ✔skin intact, red, non blanching, warm.
,stage II pressure ucer - ✔partial thickness loss of dermis, open but shallow with a red
pink wound bed.
stage III pressure ulcer - ✔deep crater full thickness skin loss with damge or necrosis to
subcut tissue. can have undermining. bone/tendon not visible
stage IV pressure ulcer - ✔full thickness skin loss, extensive damage, tissue necrosis, goes
to bone or tendon, slough or escar present.
nursing interventions to prevent pressure ulcers - ✔reposition patient every 2 hours or
more. chair bound should be repositioned every hour or taught to shift weight every 15 min
nutriton/hydration- patients with increased risk of skin integrity need a lot of protein, water,
etc. to keep their skin strong and intact, and to avoid losing weight and having more bony
prominences.
incontinence care- moisture causes decreased skin integrity
types of traumatic wounds - ✔abrasion- a scrape of the superficial layers of the skin
laceration- skin or mucous membranes are torn open, resulting in a wound with jagged margins
puncture wounds- wound caused by a sharp object.
arterial ulcers - ✔cause- inadequate circulation of oxygenated blood to the tissue, which
leads to tissue ischemia and damage
appearance- punched out, small and round with smooth borders. usually pale, with or without
necrotic tissue. delayed capillary refill. pain with increased activity
location- distal part of leg. ankles, toes, side of foot, shin
venous stasis ulcers - ✔cause- incompetent venous valves, deep vein obstruction,
or inadequate calfe muscle function, resulting in venous pooling, edema, and
impaired microcirculation of the skin
,appearance- surrounding skin is reddened or brown and swollen. wounds are shallow with
irregular woun margins. wound bed is ruddy or beefy. paid occurs with leg dependence
and dressing changes
location- inner ankle or lower claf.
hemmorhage - ✔greatest for first 24 to 48 hours after surgery or injury
could be a slipped suture, erosion of a blood vessel, dislodged clot, or infection
can be internal (hematoma) or external (a lot of blood drainage)
infection - ✔suspect infection if wound fails to heal. puss, heat, redness, etc. can cause risk
for dehiscence
dehiscence - ✔most likelu to occur in the inflammatory phase of healing, before collagen.
causes:
poor nutritional status, inadequate closure of muscles, wound infection, increased tension
on the suture line. obesity
evesceration - ✔total seperation of the layers of a wound with intrnal viscera protruding
through the incistion. cover with steril towels and have patient stay in bed with knees pent. no
binder. notify surgeon
irrigating wound - ✔cleanse by flushing
closely watch pressure and be sure not to remove granulation tissue. use gowns, masks, and
goggles
absorbant dressings - ✔used for wounds with moderate to large ammounts of drainage
nursing concerns: do not use to pack undermining wounds
do noy use if wound is not drainging
, alginates - ✔promote moist environment, high absorbency, facilitate autolytic
environment, ideal for wounds with depth, tracts, tunneling, or underming
NC: will adhere to the wound bed if there is no drainage
when comes in contact with exudate, forms gel. must irrigate
antimicrobials - ✔reduce exudate and prevent
infection promote collagen
watch for allergy to iodine or silver
collagens - ✔partial or full thickness wounds
absorb exudate
promote moist wound bed for healing
stimulate wounds to produce collagen febers
do not stick to wound bed, easy to apply and remove
NC: check that patient isnt against cow or pig use
foams - ✔absorbant
thermal insulation
promote moist environment
dont stick to wound bed
used under compression
can be shaped around body contours
NC: do not use with wounds with tunneling or tracts
gauze - ✔cleansing, protection, paching
NC: labor intensive, can stick to wound, does not ensure moist wound environment
and answers/Complete Solutions
pressure ulcer nursing assessment: where - ✔bony prominences
areas under weight
medical appliances
damp areas
intertriginous
pressure ulcer nursing assessment: what? - ✔color of skin: blanching or no
warmth
edema
change in tissue consistency
REASSESS ABNORMAL FINDINGS IN ONE HOUR
pressure ulcer nursing assessment: when? - ✔on
admission daily
as needed based on assessment findings (reasses abnormal findings within one hour)
pressure ulcer nursing assessment who? - ✔registered nurse. do not delegate
pressure ulcer nursing assessment: how? - ✔braden scale
stage I pressure ulcer - ✔skin intact, red, non blanching, warm.
,stage II pressure ucer - ✔partial thickness loss of dermis, open but shallow with a red
pink wound bed.
stage III pressure ulcer - ✔deep crater full thickness skin loss with damge or necrosis to
subcut tissue. can have undermining. bone/tendon not visible
stage IV pressure ulcer - ✔full thickness skin loss, extensive damage, tissue necrosis, goes
to bone or tendon, slough or escar present.
nursing interventions to prevent pressure ulcers - ✔reposition patient every 2 hours or
more. chair bound should be repositioned every hour or taught to shift weight every 15 min
nutriton/hydration- patients with increased risk of skin integrity need a lot of protein, water,
etc. to keep their skin strong and intact, and to avoid losing weight and having more bony
prominences.
incontinence care- moisture causes decreased skin integrity
types of traumatic wounds - ✔abrasion- a scrape of the superficial layers of the skin
laceration- skin or mucous membranes are torn open, resulting in a wound with jagged margins
puncture wounds- wound caused by a sharp object.
arterial ulcers - ✔cause- inadequate circulation of oxygenated blood to the tissue, which
leads to tissue ischemia and damage
appearance- punched out, small and round with smooth borders. usually pale, with or without
necrotic tissue. delayed capillary refill. pain with increased activity
location- distal part of leg. ankles, toes, side of foot, shin
venous stasis ulcers - ✔cause- incompetent venous valves, deep vein obstruction,
or inadequate calfe muscle function, resulting in venous pooling, edema, and
impaired microcirculation of the skin
,appearance- surrounding skin is reddened or brown and swollen. wounds are shallow with
irregular woun margins. wound bed is ruddy or beefy. paid occurs with leg dependence
and dressing changes
location- inner ankle or lower claf.
hemmorhage - ✔greatest for first 24 to 48 hours after surgery or injury
could be a slipped suture, erosion of a blood vessel, dislodged clot, or infection
can be internal (hematoma) or external (a lot of blood drainage)
infection - ✔suspect infection if wound fails to heal. puss, heat, redness, etc. can cause risk
for dehiscence
dehiscence - ✔most likelu to occur in the inflammatory phase of healing, before collagen.
causes:
poor nutritional status, inadequate closure of muscles, wound infection, increased tension
on the suture line. obesity
evesceration - ✔total seperation of the layers of a wound with intrnal viscera protruding
through the incistion. cover with steril towels and have patient stay in bed with knees pent. no
binder. notify surgeon
irrigating wound - ✔cleanse by flushing
closely watch pressure and be sure not to remove granulation tissue. use gowns, masks, and
goggles
absorbant dressings - ✔used for wounds with moderate to large ammounts of drainage
nursing concerns: do not use to pack undermining wounds
do noy use if wound is not drainging
, alginates - ✔promote moist environment, high absorbency, facilitate autolytic
environment, ideal for wounds with depth, tracts, tunneling, or underming
NC: will adhere to the wound bed if there is no drainage
when comes in contact with exudate, forms gel. must irrigate
antimicrobials - ✔reduce exudate and prevent
infection promote collagen
watch for allergy to iodine or silver
collagens - ✔partial or full thickness wounds
absorb exudate
promote moist wound bed for healing
stimulate wounds to produce collagen febers
do not stick to wound bed, easy to apply and remove
NC: check that patient isnt against cow or pig use
foams - ✔absorbant
thermal insulation
promote moist environment
dont stick to wound bed
used under compression
can be shaped around body contours
NC: do not use with wounds with tunneling or tracts
gauze - ✔cleansing, protection, paching
NC: labor intensive, can stick to wound, does not ensure moist wound environment
