NSG 300 Exam 2 | Updated
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Terms in this set (258)
what places pressure intensity, pressure
patients at risk duration, tissue tolerance, impaired
for pressure sensory perception, impaired
ulcers/impaired mobility, alteration in LOC, shear,
skin integrity friction, moisture
layers of the epidermis, dermis (collagen)
skin
,body's defenses normal flora, inflammatory
against response, immune response
infection
-ongoing assessment from time of
injury, wound care, any condition
changes, and on scheduled basis
comprehensive
-Important to include cause of
wound
injury, history of wound, treatment,
assessment
description, response to therapy
-Braden scale: assesses risk for
pressure/skin injury every shift
assesses risk for developing
pressure ulcers; includes patient's
sensory perception, moisture,
activity, mobility, nutrition, friction
and shear; the lower the number
Braden Scale 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
, skin is intact but may be red or pink
and warm to the touch; no
blanching
type 1 ulcers
-for POC, there may be no
noticeable blanching but skin
color may vary
partial-thickness loss of dermis;
type 2 ulcers shallow broken skin; red-pink
wound bed
full-thickness tissue loss with
visible fat (subcutaneous layer);
type 3 ulcers pale-yellow color; may include
slough but does not obstruct view
of depth of injury
full-thickness tissue loss with
exposed bone, muscle, or tendon.
type 4 ulcers
possible tunneling and
undermining
base of ulcer covered by slough
unstageable
and/or eschar in the wound bed so
pressure ulcer
the depth is unknown; exudate;
Questions and Correct Answers |
Graded A+ | Verified Answers |
Latest Versions
Save
Terms in this set (258)
what places pressure intensity, pressure
patients at risk duration, tissue tolerance, impaired
for pressure sensory perception, impaired
ulcers/impaired mobility, alteration in LOC, shear,
skin integrity friction, moisture
layers of the epidermis, dermis (collagen)
skin
,body's defenses normal flora, inflammatory
against response, immune response
infection
-ongoing assessment from time of
injury, wound care, any condition
changes, and on scheduled basis
comprehensive
-Important to include cause of
wound
injury, history of wound, treatment,
assessment
description, response to therapy
-Braden scale: assesses risk for
pressure/skin injury every shift
assesses risk for developing
pressure ulcers; includes patient's
sensory perception, moisture,
activity, mobility, nutrition, friction
and shear; the lower the number
Braden Scale 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
, skin is intact but may be red or pink
and warm to the touch; no
blanching
type 1 ulcers
-for POC, there may be no
noticeable blanching but skin
color may vary
partial-thickness loss of dermis;
type 2 ulcers shallow broken skin; red-pink
wound bed
full-thickness tissue loss with
visible fat (subcutaneous layer);
type 3 ulcers pale-yellow color; may include
slough but does not obstruct view
of depth of injury
full-thickness tissue loss with
exposed bone, muscle, or tendon.
type 4 ulcers
possible tunneling and
undermining
base of ulcer covered by slough
unstageable
and/or eschar in the wound bed so
pressure ulcer
the depth is unknown; exudate;
