D439 Foundations of Nursing
1. What are things to pro- -Routine sleep schedule,
mote sleep? -PM should involve a cool/dark room, reduce any stimuli in the
bedroom, and no naps in the afternoon; if they do, limit to 20 mins
per day.
-AM should involve a sunny/bright room,
-Do not turn off alarms in pts room
-Do not increase sedation at night
-Replicate your pts sleep schedule
-Avoid these 4-6hrs before bed: caffeine, chocolate (any form), soda,
tea, alcohol, nicotine, exercise, going to bed hungry or too full.
2. What is the minimum time 15 seconds
one should wash their
hands?
3. How would you take care Follow your hospital's recommendations. Debridement if needed,
of a wound? keep moist, clean, monitor for signs of infection.
4. What occurs in a pressure Intact skin with persistent, nonblanchable redness that can feel
wound stage one? warmer or cooler than the adjacent tissue.
5. What occurs in a pressure Involves the epidermis and the dermis. The wound bed is viable with
wound stage two? a reddish-pinkish bed without slough, eschar, granulation tissue, or
adipose tissue. It can appear as an intact or ruptured blister.
6. What occurs in a pressure Visible adipose tissue with possible granulation tissue and wound
wound stage three? edges appear rolled under; some slough, eschar present. Affects the
epidermis, dermis, and subcutaneous tissue.
7. What occurs in a pressure Skin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or
wound stage four? tendon exposed in the wound or easily palpable.
8. Eschar and slough make it impossible to see. Perform debridement.
, D439 Foundations of Nursing
What occurs in a pressure
wound that is unstage-
able?
9. What occurs when the Intact skin is nonblanchable with deep red, maroon, or purple dis-
pressure wound is at the coloration; open wounds have a dark wound bed or blood blister.
deep tissue? Pain and temperature changes can be detected earlier than col-
or changes. Occurs most frequently over the heels, ankles, ischial
tuberosities, and sacral area.
10. During the healing -Little or no tissue loss
process of a wound, what -Heals rapidly, low risk for infection, and no/minimal scarring
occurs during the primary -Ex. closed surgical incision with staples, sutures, or liquid glue to
intention stage? seal laceration
11. During the healing -Loss of tissue
process of a wound, what -Longer healing time, increased risk for infection, scarring, and is
occurs during the sec- healed by granulation
ondary intention stage? -Ex. pressure injury left open to heal
12. During the healing -Tissue is deep and is widely separated
process of a wound, what -Spontaneous opening of a previously closed wound; closure of these
occurs during the tertiary wounds occurs when they are free of infection and edema
intention stage? -Long healing time, risk of infection, extensive drainage and tissue
debris
-Ex. abdominal wound initially left open until infection is resolved and
then closed
13. What is serous drainage Portion of the blood that is watery, clear, sometimes slightly yellow in
from a wound? appearance.
14. What is sanguineous
drainage from a wound?
1. What are things to pro- -Routine sleep schedule,
mote sleep? -PM should involve a cool/dark room, reduce any stimuli in the
bedroom, and no naps in the afternoon; if they do, limit to 20 mins
per day.
-AM should involve a sunny/bright room,
-Do not turn off alarms in pts room
-Do not increase sedation at night
-Replicate your pts sleep schedule
-Avoid these 4-6hrs before bed: caffeine, chocolate (any form), soda,
tea, alcohol, nicotine, exercise, going to bed hungry or too full.
2. What is the minimum time 15 seconds
one should wash their
hands?
3. How would you take care Follow your hospital's recommendations. Debridement if needed,
of a wound? keep moist, clean, monitor for signs of infection.
4. What occurs in a pressure Intact skin with persistent, nonblanchable redness that can feel
wound stage one? warmer or cooler than the adjacent tissue.
5. What occurs in a pressure Involves the epidermis and the dermis. The wound bed is viable with
wound stage two? a reddish-pinkish bed without slough, eschar, granulation tissue, or
adipose tissue. It can appear as an intact or ruptured blister.
6. What occurs in a pressure Visible adipose tissue with possible granulation tissue and wound
wound stage three? edges appear rolled under; some slough, eschar present. Affects the
epidermis, dermis, and subcutaneous tissue.
7. What occurs in a pressure Skin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or
wound stage four? tendon exposed in the wound or easily palpable.
8. Eschar and slough make it impossible to see. Perform debridement.
, D439 Foundations of Nursing
What occurs in a pressure
wound that is unstage-
able?
9. What occurs when the Intact skin is nonblanchable with deep red, maroon, or purple dis-
pressure wound is at the coloration; open wounds have a dark wound bed or blood blister.
deep tissue? Pain and temperature changes can be detected earlier than col-
or changes. Occurs most frequently over the heels, ankles, ischial
tuberosities, and sacral area.
10. During the healing -Little or no tissue loss
process of a wound, what -Heals rapidly, low risk for infection, and no/minimal scarring
occurs during the primary -Ex. closed surgical incision with staples, sutures, or liquid glue to
intention stage? seal laceration
11. During the healing -Loss of tissue
process of a wound, what -Longer healing time, increased risk for infection, scarring, and is
occurs during the sec- healed by granulation
ondary intention stage? -Ex. pressure injury left open to heal
12. During the healing -Tissue is deep and is widely separated
process of a wound, what -Spontaneous opening of a previously closed wound; closure of these
occurs during the tertiary wounds occurs when they are free of infection and edema
intention stage? -Long healing time, risk of infection, extensive drainage and tissue
debris
-Ex. abdominal wound initially left open until infection is resolved and
then closed
13. What is serous drainage Portion of the blood that is watery, clear, sometimes slightly yellow in
from a wound? appearance.
14. What is sanguineous
drainage from a wound?
