NDSU NURS 251 EXAM 2 SKIN_WOUND CARE QUESTIONS WITH CORRECT ANSWERS

Arterial Ulcers- Goals of Care


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-Improve circulation (ROM, Consult provider, surgery)
-New non-invasive procedure available
-May be a combination of arterial/venous




Nursing Assistants roles


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, -vitals
-ongoing skin care needs
-surveillance
-prevention




Stage 3- Pressure ulcer


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-full thickness tissue loss
-subcutaneous tissue visible
-tunneling
-scattered slough
-depth depends on anatomical location




Suspected Deep Tissue Injury (DTI)


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-purple or maroon area
-intact skin
-blood-filled blister
-painful, firm, mushy, boggy (squishy tissue)
-difficult to detect in people with dark skin tones




Local wound healing delays


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, -Pressure (impedes blood flow)
-Desiccation (dry skin)
-Maceration (too much moisture)
-Trauma (repeated injury)
-Edema (interferes with transportation of O2 and nutrition)
-Tissue Necrosis (magnet for bacteria, bacteria steal nutrition from healthy
tissue)




Serous drainage


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clear, watery fluid




Slough


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moist, loose, stringy tissue, yellow

Remove with saline and gauze after giving pain meds




Risk Factors for Skin Tears


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