NSG 300 Exam 2 Questions With Complete Solution

NSG 300 Exam 2 Questions With Complete Solution what places patients at risk for pressure ulcers/impaired skin integrity - answerpressure intensity, pressure duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in LOC, shear, friction, moisture layers of the skin - answerepidermis, dermis (collagen) body's defenses against infection - answernormal flora, inflammatory response, immune response comprehensive wound assessment - answer-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 - answerassesses 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 - answerskin 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 - answerpartial-thickness loss of dermis; shallow broken skin; red-pink wound bed type 3 ulcers - answerfull-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 - answerfull-thickness tissue loss with exposed bone, muscle, or tendon. possible tunneling and undermining unstageable pressure ulcer - answerbase of ulcer covered by slough and/or eschar in the wound bed so the depth is unknown; exudate; deep tissue injury - answerPurple 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 - answerfrom least to most contaminated eschar - answerblack, brown or necrotic tissue in wound bed; needs to be removed before healing slough - answerstringy pale-yellowish tissue that lays in the wound bed; needs to be removed before healing if a patient has slough, eschar, and infectious exudate which one would you be most concerned about - answerinfectious exudate factors influencing heat and cold tolerance - answerExposure time Exposed skin Temperature Age Perception of sensory stimuli assessment for pressure ulcers includes - answerlocation, staging (depth), type and % of tissue in wound bed, wound dimensions