NUR
NUR155
155Exam
Exam3 (unit 6-7)
3 (unit - converted
6-7)
NUR 155 Exam 3 (unit 6-7)
Study online at https://quizlet.com/_joau4k
1. Factors that alter the -diseases
structure & function -nutrition
of skin -medication use
-external forces ( pressure/shear)
-aging
2. Braden Scare predicts pressure sore risk by using categories; sensory perception, mois-
ture, activity, mobility, nutrition, friction, and shear
3. Norton Scale measures pressure ulcers by using categories; physical condition, mental
state, activity, mobility, continence.
4. Prioritizing greatest identify age, any infection, medical devices, diabetes?
risk
5. Stage 1 pressure in- nonblanchable erythema of intact skin, temp different than surrounding skin
jury
6. Stage 2 pressure in- shallow/superficial, partial thickness skin loss, exposed dermis, intact/rup-
jury tured blisters
7. Stage 3 pressure in- full-thickness skin loss reaching subcutaneous tissue, potential undermining
jury (tissue loss under intact skin, "lip"), and tunneling
PagePage
1 of 23
1
, NUR
NUR155
155Exam
Exam3 (unit 6-7)
3 (unit - converted
6-7)
NUR 155 Exam 3 (unit 6-7)
Study online at https://quizlet.com/_joau4k
8. Stage 4 pressure in- Full-thickness skin and tissue loss, osteomyelitis, exposure to muscle, bone,
jury or connective tissue
9. Unstageable pres- full-thickness skin & tissue loss, unable to assess depth until eschar is
sure injury removed
10. Deep tissue pressure intact persistent, nonblanchable, deep red, maroon, purple discoloration
injury
11. Ture or False True
as healing takes
place, a pressure in-
jury will not be able
to return to a normal
state prior to injury
12. Serous Drainage contains clear/yellow watery fluid from plasma
13. Serosanguineous pink - pale red, mix of serous fluid and red/bloody fluid
Draingage
14. Sanguineous indicates bleeding, bright red.
15. Purulent thick, yellow-greenish-beige, indicates infection
16. Dehiscence PARTIAL/COMPLETE separation of tissue layers during the healing process
17. Evisceration -TOTAL separation of tissue layers, causing protrusion of visceral organs
"popping" sensation
18. caring for dehis- -cover wound with sterile saline-moistened gauze
cence or evisceration - notify provider
19. visible redness, warmth, increased drainage, MAY or MAY NOT be purulent
PagePage
2 of 23
2
, NUR
NUR155
155Exam
Exam3 (unit 6-7)
3 (unit - converted
6-7)
NUR 155 Exam 3 (unit 6-7)
Study online at https://quizlet.com/_joau4k
How to identify an in-
fected wound
20. Primary intention ACUTE WOUND= heals quickly, minimal scar formation
healing ex: surgical incisions, traumatic wounds
21. Secondary intention CHRONIC WOUND= stay open for period of time to allow for drainage and
healing observation, once infection lowers it is closed, new tissue growth begins
from BOTTOM-TOP
22. Tertiary intention CHRONIC WOUND= delay occurs between injury and closure
healing ex: G.I tract surgery
23. Vitamins aiding in A.C.E
healing of pressure
wounds
24. Only RN's Eat E:valuate
A: ssess
T: each
25. Sharp Debridement removal of eschar using sharp instruments, fastest way of removing nonvi-
able tissue, method of choice if infection is suspected
26. Mechanical Debride- removes eschar; wet/damp to dry dressings usually saline-moistened.
ment Quickest form
27. Enzymatic Debride- applying topical agents containing enzymes that break down fibrin and
ment collagen.
28. Autolytic Debride- Wounds have the innate ability to clean themselves of debris and eschar.
ment Slowest form.
EX: occlusive dressings; hydrocolloids, transparent films,
PagePage
3 of 23
3
NUR155
155Exam
Exam3 (unit 6-7)
3 (unit - converted
6-7)
NUR 155 Exam 3 (unit 6-7)
Study online at https://quizlet.com/_joau4k
1. Factors that alter the -diseases
structure & function -nutrition
of skin -medication use
-external forces ( pressure/shear)
-aging
2. Braden Scare predicts pressure sore risk by using categories; sensory perception, mois-
ture, activity, mobility, nutrition, friction, and shear
3. Norton Scale measures pressure ulcers by using categories; physical condition, mental
state, activity, mobility, continence.
4. Prioritizing greatest identify age, any infection, medical devices, diabetes?
risk
5. Stage 1 pressure in- nonblanchable erythema of intact skin, temp different than surrounding skin
jury
6. Stage 2 pressure in- shallow/superficial, partial thickness skin loss, exposed dermis, intact/rup-
jury tured blisters
7. Stage 3 pressure in- full-thickness skin loss reaching subcutaneous tissue, potential undermining
jury (tissue loss under intact skin, "lip"), and tunneling
PagePage
1 of 23
1
, NUR
NUR155
155Exam
Exam3 (unit 6-7)
3 (unit - converted
6-7)
NUR 155 Exam 3 (unit 6-7)
Study online at https://quizlet.com/_joau4k
8. Stage 4 pressure in- Full-thickness skin and tissue loss, osteomyelitis, exposure to muscle, bone,
jury or connective tissue
9. Unstageable pres- full-thickness skin & tissue loss, unable to assess depth until eschar is
sure injury removed
10. Deep tissue pressure intact persistent, nonblanchable, deep red, maroon, purple discoloration
injury
11. Ture or False True
as healing takes
place, a pressure in-
jury will not be able
to return to a normal
state prior to injury
12. Serous Drainage contains clear/yellow watery fluid from plasma
13. Serosanguineous pink - pale red, mix of serous fluid and red/bloody fluid
Draingage
14. Sanguineous indicates bleeding, bright red.
15. Purulent thick, yellow-greenish-beige, indicates infection
16. Dehiscence PARTIAL/COMPLETE separation of tissue layers during the healing process
17. Evisceration -TOTAL separation of tissue layers, causing protrusion of visceral organs
"popping" sensation
18. caring for dehis- -cover wound with sterile saline-moistened gauze
cence or evisceration - notify provider
19. visible redness, warmth, increased drainage, MAY or MAY NOT be purulent
PagePage
2 of 23
2
, NUR
NUR155
155Exam
Exam3 (unit 6-7)
3 (unit - converted
6-7)
NUR 155 Exam 3 (unit 6-7)
Study online at https://quizlet.com/_joau4k
How to identify an in-
fected wound
20. Primary intention ACUTE WOUND= heals quickly, minimal scar formation
healing ex: surgical incisions, traumatic wounds
21. Secondary intention CHRONIC WOUND= stay open for period of time to allow for drainage and
healing observation, once infection lowers it is closed, new tissue growth begins
from BOTTOM-TOP
22. Tertiary intention CHRONIC WOUND= delay occurs between injury and closure
healing ex: G.I tract surgery
23. Vitamins aiding in A.C.E
healing of pressure
wounds
24. Only RN's Eat E:valuate
A: ssess
T: each
25. Sharp Debridement removal of eschar using sharp instruments, fastest way of removing nonvi-
able tissue, method of choice if infection is suspected
26. Mechanical Debride- removes eschar; wet/damp to dry dressings usually saline-moistened.
ment Quickest form
27. Enzymatic Debride- applying topical agents containing enzymes that break down fibrin and
ment collagen.
28. Autolytic Debride- Wounds have the innate ability to clean themselves of debris and eschar.
ment Slowest form.
EX: occlusive dressings; hydrocolloids, transparent films,
PagePage
3 of 23
3
