NFDN 1002 FINAL REVIEW
11 medication rights - ✅✅-Person
Drug/Medication
Dose
Route
Time
Assessment
Reason
Education
Documentation
Evaluation
Refuse
different routes of medication administration - ✅✅ -SC
IM
IV
Subdermal
PO - by mouth
Topical - inhaler, cream, spray, rectal, drops, sublingual (under tongue), buccal
(cheek), transdermal
different stages of pressure ulcers - ✅✅-Deep Tissue Injury
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Deep Tissue Injury - ✅✅ -Persistent non-blanchable deep red, purple discoloration
Epidermis separated, blister
Results from prolonged pressure
Stage 1 Pressure Ulcer - ✅✅
-Non-blanchable erythema of area
Over bony prominence
Skin discolouration
Warmth; edema; hardness; pain
Darker skin
No visible blanching
Area painful; firmer/softer
Warm/cooler
Managing Stage 1 Pressure Ulcer - ✅✅-Relieve pressure
Barrier cream
, Stage 2 Pressure Ulcer - ✅✅ -Partial thickness skin loss or blister
Shallow open ulcer ; pink wound bed
No slough/bruising
Management of Stage 2 Pressure Ulcer - ✅✅-transparent film
Stage 3 Pressure Ulcer - ✅✅-Full thickness skin loss
Necrosis & drainage
Infection develops
Managing Stage 3 Pressure Ulcer - ✅✅-Treated with wound vacuum assisted
closure
surgical - skin closure, flaps, grafting
synthetic gauze
Stage 4 Pressure Ulcer - ✅✅-Extends to underlying muscle & bone
Deep pockets of infection
Necrosis & drainage
Management of Stage 4 Pressure Ulcer - ✅✅-Foam dressings
Wound vacuum
Unstagable Pressure Ulcer - ✅✅
-Full thickness skin & tissue loss
Tissue damage undetermined - presence of slough/discharge & eschar
Negative Pressure Wound Therapy [NPWT] - ✅✅
-promotes wound healing and
closure
application of negative pressure on wound bed = decreased bacteria, removal of
excess drainage
provides moist environment
pressure stimulates blood flow & cell growth
growth of new blood vessels
Pressure Ulcer Contributing Factors - ✅✅
-Nutritional deficiencies
Anemia - Decrease blood O2 carrying capacity
Vitamin D
Metabolic disorders - low protein levels
4 places that you would assess for pressure ulcer development - ✅✅ -heels,
shoulders, coccyx, sacrum, spine, elbows, scapula, back of head, toes, greater
trochanter, iliac crest, ear, knees, breasts, cheek, mens genitalia
3 strategies for pressure ulcer prevention - ✅✅-braden scale
11 medication rights - ✅✅-Person
Drug/Medication
Dose
Route
Time
Assessment
Reason
Education
Documentation
Evaluation
Refuse
different routes of medication administration - ✅✅ -SC
IM
IV
Subdermal
PO - by mouth
Topical - inhaler, cream, spray, rectal, drops, sublingual (under tongue), buccal
(cheek), transdermal
different stages of pressure ulcers - ✅✅-Deep Tissue Injury
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Deep Tissue Injury - ✅✅ -Persistent non-blanchable deep red, purple discoloration
Epidermis separated, blister
Results from prolonged pressure
Stage 1 Pressure Ulcer - ✅✅
-Non-blanchable erythema of area
Over bony prominence
Skin discolouration
Warmth; edema; hardness; pain
Darker skin
No visible blanching
Area painful; firmer/softer
Warm/cooler
Managing Stage 1 Pressure Ulcer - ✅✅-Relieve pressure
Barrier cream
, Stage 2 Pressure Ulcer - ✅✅ -Partial thickness skin loss or blister
Shallow open ulcer ; pink wound bed
No slough/bruising
Management of Stage 2 Pressure Ulcer - ✅✅-transparent film
Stage 3 Pressure Ulcer - ✅✅-Full thickness skin loss
Necrosis & drainage
Infection develops
Managing Stage 3 Pressure Ulcer - ✅✅-Treated with wound vacuum assisted
closure
surgical - skin closure, flaps, grafting
synthetic gauze
Stage 4 Pressure Ulcer - ✅✅-Extends to underlying muscle & bone
Deep pockets of infection
Necrosis & drainage
Management of Stage 4 Pressure Ulcer - ✅✅-Foam dressings
Wound vacuum
Unstagable Pressure Ulcer - ✅✅
-Full thickness skin & tissue loss
Tissue damage undetermined - presence of slough/discharge & eschar
Negative Pressure Wound Therapy [NPWT] - ✅✅
-promotes wound healing and
closure
application of negative pressure on wound bed = decreased bacteria, removal of
excess drainage
provides moist environment
pressure stimulates blood flow & cell growth
growth of new blood vessels
Pressure Ulcer Contributing Factors - ✅✅
-Nutritional deficiencies
Anemia - Decrease blood O2 carrying capacity
Vitamin D
Metabolic disorders - low protein levels
4 places that you would assess for pressure ulcer development - ✅✅ -heels,
shoulders, coccyx, sacrum, spine, elbows, scapula, back of head, toes, greater
trochanter, iliac crest, ear, knees, breasts, cheek, mens genitalia
3 strategies for pressure ulcer prevention - ✅✅-braden scale
