NSG-300 Exam 2 UPDATED ACTUAL Questions and CORRECT
Answers
what places patients at risk for pressure ulcers/impaired pressure intensity, pressure duration, tissue tolerance, impaired sensory
skin integrity perception, impaired mobility, alteration in LOC, shear, friction, moisture
layers of the skin epidermis, dermis (collagen)
body's defenses against infection normal flora, inflammatory response, immune response
comprehensive wound assessment -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 assesses 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 skin 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 partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers full-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 full-thickness tissue loss with exposed bone, muscle, or tendon. possible
tunneling and undermining
unstageable pressure ulcer base of ulcer covered by slough and/or eschar in the wound bed so the depth is
unknown; exudate;
deep tissue injury Purple 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 from least to most contaminated
eschar black, brown or necrotic tissue in wound bed; needs to be removed before
healing
, slough stringy pale-yellowish tissue that lays in the wound bed; needs to be removed
before healing
if a patient has slough, eschar, and infectious exudate infectious exudate
which one would you be most concerned about
factors influencing heat and cold tolerance Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes location, 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 because the wound heals inside-out
granulation tissue good, 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? by 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? by 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 wound that is closed/approximated; little tissue loss; low risk of infection; quick
healing with no scar usually (surgical incision)
secondary intention a 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 Wound that is left open for several days, then wound edges are approximated;
doctor can monitor status of wound
Answers
what places patients at risk for pressure ulcers/impaired pressure intensity, pressure duration, tissue tolerance, impaired sensory
skin integrity perception, impaired mobility, alteration in LOC, shear, friction, moisture
layers of the skin epidermis, dermis (collagen)
body's defenses against infection normal flora, inflammatory response, immune response
comprehensive wound assessment -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 assesses 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 skin 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 partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers full-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 full-thickness tissue loss with exposed bone, muscle, or tendon. possible
tunneling and undermining
unstageable pressure ulcer base of ulcer covered by slough and/or eschar in the wound bed so the depth is
unknown; exudate;
deep tissue injury Purple 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 from least to most contaminated
eschar black, brown or necrotic tissue in wound bed; needs to be removed before
healing
, slough stringy pale-yellowish tissue that lays in the wound bed; needs to be removed
before healing
if a patient has slough, eschar, and infectious exudate infectious exudate
which one would you be most concerned about
factors influencing heat and cold tolerance Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes location, 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 because the wound heals inside-out
granulation tissue good, 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? by 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? by 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 wound that is closed/approximated; little tissue loss; low risk of infection; quick
healing with no scar usually (surgical incision)
secondary intention a 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 Wound that is left open for several days, then wound edges are approximated;
doctor can monitor status of wound
