NSG-300 Foundations of Nursing Assessment
2 Solved 100% Correct-GCU
What are 3 pressure related factors that contribute to pressure ulcer development?
- ANSWER-1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - ANSWER-If pressure applied over a
capillary exceeds normal capillary pressure and the vessel is occluded for a
prolonged time
What occurs is tissue ischemia is left untreated? - ANSWER-tissue death
Does blanching occur in dark skinned patients? - ANSWER-No, blanching does not
occur but color, texture and temp may differ from surrounding area
What does pressure duration assess? - ANSWER-Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? - ANSWER-the ability of tissue to endure pressure which is
dependent on the integrity of the tissue and supporting structures
What are risk factors of pressure injuries? - ANSWER-◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - ANSWER-
Wound location, staging, type and approximate percentage of tissue in wound bed,
wound dimensions (sinus tracts and tunneling), exudate description and condition
of surrounding skin
stage 1 pressure injury - ANSWER-Intact skin with nonblanchable redness
stage 2 pressure injury - ANSWER-partial thickness skin loss involving epidermis,
dermis or both and, shallow abrasion or open blister looking
stage 3 pressure injury - ANSWER-full thickness skin loss extending to SQ, crater
,looking
stage 4 pressure injury - ANSWER-full thickness with exposed bone, muscle or
tendon and may have eschar
What characteristics does stage 3 and 4 pressure injuries share? - ANSWER-They
may have slough, undermining and tunneling present
A nurse states slough is present in a stage 3 pressure injury. What should the
student nurse expect to see? - ANSWER-A yellow or white, stringy substance
attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should the
student nurse expect to see? - ANSWER-brown or black necrotic tissue
Unstageable/Unclassified Pressure Ulcer - ANSWER-Tissue loss but depth unknown
because wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and states "it
will heal on its own". What education should the nurse provide? - ANSWER-Slough
and eschar must be removed by a clinician to determine the stage and in order for
healing to occur
suspected deep tissue injury - ANSWER-Purple or maroon localized area of
discolored intact skin or blood-filled blister due to damage of underlying soft tissue
from pressure and/or shear. Depth unknown
A nurse is assessing a wound and notes the presence of granulation tissue. What
should the student nurse expect to see? - ANSWER-Red, moist tissue which
indicates progression toward healing
What should the nurse document when assessing exudate? - ANSWER-Amount,
color, consistency and odor
The student nurse sees an excess amount of exudate in the wound bed. What does
this indicate? - ANSWER-The presence of infection
What should the nurse look for when assessing the periwound area? Why is it
important? - ANSWER-Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
Why is wound classification important? - ANSWER-Allows a nurse to understand the
risks associated with a wound and implications for healing
How does a partial thickness wound heal? - ANSWER-Heals by regeneration
How does a full thickness would heal? - ANSWER-Heals by forming new tissue
which takes longer
, What are the three components involved in the healing process of a partial
thickness wound? - ANSWER-Inflammatory response, epithelial proliferation and
migration, and reestablishment of epidermal layers
A patient states keeping his wound exposed to air while allow his wound to heal
quickly. What education should the nurse provide to the patient? - ANSWER-
Wounds heal faster in moist environments because epidermal cells only migrate
across moist surfaces.
Reestablishment of the epidermal layers - ANSWER-New epithelium is only a few
cells thick. Cells slowly reestablish normal thickness and appear as dry, pink tissue
What are the four stages involved in the healing process of a full thickness wound?
- ANSWER-Hemostasis, inflammation, proliferation and maturation
Primary intention healing - ANSWER-The skin edges are approximated, or closed,
and the risk of infection is low. Healing occurs quickly, with minimal scar formation,
as long as infection and secondary breakdown are prevented
Secondary infection healing - ANSWER-Wound is left open until it becomes filed by
scar tissue. It takes longer for a wound to heal by secondary intention increasing
the chance of infection
hemorrhage - ANSWER-bleeding from a wound site is normal during and
immediately after initial trauma
A nurse suspects internal bleeding. How would the nurses assess the patient to
confirm her findings? - ANSWER-By assessing for distention or swelling of the
affected body part, change in type and amount of drainage from a surgical drain r
signs of hypovolemic shock
Hematoma - ANSWER-localized collection of blood underneath the tissue
dihiscence - ANSWER-partial or total separation of wound layers
Evisceration - ANSWER-protrusion of visceral organs through a wound opening
What is the second most common health care associated infection? - ANSWER-
wound infection
What are the signs and symptoms of wound infection? - ANSWER-Fever, tenderness
and pain at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
A student nurse is asked to perform a risk assessment of pressure ulcers on
2 Solved 100% Correct-GCU
What are 3 pressure related factors that contribute to pressure ulcer development?
- ANSWER-1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - ANSWER-If pressure applied over a
capillary exceeds normal capillary pressure and the vessel is occluded for a
prolonged time
What occurs is tissue ischemia is left untreated? - ANSWER-tissue death
Does blanching occur in dark skinned patients? - ANSWER-No, blanching does not
occur but color, texture and temp may differ from surrounding area
What does pressure duration assess? - ANSWER-Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? - ANSWER-the ability of tissue to endure pressure which is
dependent on the integrity of the tissue and supporting structures
What are risk factors of pressure injuries? - ANSWER-◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - ANSWER-
Wound location, staging, type and approximate percentage of tissue in wound bed,
wound dimensions (sinus tracts and tunneling), exudate description and condition
of surrounding skin
stage 1 pressure injury - ANSWER-Intact skin with nonblanchable redness
stage 2 pressure injury - ANSWER-partial thickness skin loss involving epidermis,
dermis or both and, shallow abrasion or open blister looking
stage 3 pressure injury - ANSWER-full thickness skin loss extending to SQ, crater
,looking
stage 4 pressure injury - ANSWER-full thickness with exposed bone, muscle or
tendon and may have eschar
What characteristics does stage 3 and 4 pressure injuries share? - ANSWER-They
may have slough, undermining and tunneling present
A nurse states slough is present in a stage 3 pressure injury. What should the
student nurse expect to see? - ANSWER-A yellow or white, stringy substance
attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should the
student nurse expect to see? - ANSWER-brown or black necrotic tissue
Unstageable/Unclassified Pressure Ulcer - ANSWER-Tissue loss but depth unknown
because wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and states "it
will heal on its own". What education should the nurse provide? - ANSWER-Slough
and eschar must be removed by a clinician to determine the stage and in order for
healing to occur
suspected deep tissue injury - ANSWER-Purple or maroon localized area of
discolored intact skin or blood-filled blister due to damage of underlying soft tissue
from pressure and/or shear. Depth unknown
A nurse is assessing a wound and notes the presence of granulation tissue. What
should the student nurse expect to see? - ANSWER-Red, moist tissue which
indicates progression toward healing
What should the nurse document when assessing exudate? - ANSWER-Amount,
color, consistency and odor
The student nurse sees an excess amount of exudate in the wound bed. What does
this indicate? - ANSWER-The presence of infection
What should the nurse look for when assessing the periwound area? Why is it
important? - ANSWER-Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
Why is wound classification important? - ANSWER-Allows a nurse to understand the
risks associated with a wound and implications for healing
How does a partial thickness wound heal? - ANSWER-Heals by regeneration
How does a full thickness would heal? - ANSWER-Heals by forming new tissue
which takes longer
, What are the three components involved in the healing process of a partial
thickness wound? - ANSWER-Inflammatory response, epithelial proliferation and
migration, and reestablishment of epidermal layers
A patient states keeping his wound exposed to air while allow his wound to heal
quickly. What education should the nurse provide to the patient? - ANSWER-
Wounds heal faster in moist environments because epidermal cells only migrate
across moist surfaces.
Reestablishment of the epidermal layers - ANSWER-New epithelium is only a few
cells thick. Cells slowly reestablish normal thickness and appear as dry, pink tissue
What are the four stages involved in the healing process of a full thickness wound?
- ANSWER-Hemostasis, inflammation, proliferation and maturation
Primary intention healing - ANSWER-The skin edges are approximated, or closed,
and the risk of infection is low. Healing occurs quickly, with minimal scar formation,
as long as infection and secondary breakdown are prevented
Secondary infection healing - ANSWER-Wound is left open until it becomes filed by
scar tissue. It takes longer for a wound to heal by secondary intention increasing
the chance of infection
hemorrhage - ANSWER-bleeding from a wound site is normal during and
immediately after initial trauma
A nurse suspects internal bleeding. How would the nurses assess the patient to
confirm her findings? - ANSWER-By assessing for distention or swelling of the
affected body part, change in type and amount of drainage from a surgical drain r
signs of hypovolemic shock
Hematoma - ANSWER-localized collection of blood underneath the tissue
dihiscence - ANSWER-partial or total separation of wound layers
Evisceration - ANSWER-protrusion of visceral organs through a wound opening
What is the second most common health care associated infection? - ANSWER-
wound infection
What are the signs and symptoms of wound infection? - ANSWER-Fever, tenderness
and pain at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
A student nurse is asked to perform a risk assessment of pressure ulcers on
