NSG 300 Topic 4 Questions With Complete Solutions.

NSG 300 Topic 4 Questions With Complete Solutions. pressure ulcers - answera localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction. what are some other names for a pressure ulcer? - answerPressure sore, decubitus ulcer, or bed sore what are the three major elements that cause a pressure ulcer? - answerpressure intensity (tissue ischemia & blanching) pressure duration tissue tolerance tissue ischemia - answerIf pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time blanching - answerBlanching occurs when the normal red tones of skin are absent. pressure duration - answerPressure duration assesses low and extended pressures. Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death. tissue tolerance - answerThe ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures. what assessment is included for a pressure ulcer? - answer-wound location -depth of tissue involvement (staging) -type and approximate percentage of tissue in wound bed -wound dimensions (if present include sinus tracts and tunneling) -exudate description (if present odor) -condition of surrounding skin. what are the risk factors for a pressure ulcer - answer-Impaired sensory perception -Impaired mobility -Alteration in LOC -Shear -Friction -Moisture stage I - answero Intact skin with nonblanchable redness of a localized area usually over a bony prominence -Discoloration of the skin, warmth, edema, hardness, or pain may also be present. stage II - answero Partial-thickness skin loss involving epidermis, dermis, or both -Presenting as a shallow open ulcer with a red pink wound bed, without slough. -May also present as an intact or op