Galen college of nursing NUR 155 exam 3 study set with complete solutions...
Galen college of nursing NUR 155 exam 3 study set
Study online at https://quizlet.com/_djvvi1
1. Characteristics of A nonblanchable area with redness
a stage 1 pres-
sure ulcer Has minor soft tissue swelling and warmth to area
Skin is intact
Normally reversible with appropriate nursing care
2. Characteristics of Partial thickness with loss of skin including the epidermis and or dermis
a stage 2 pres-
sure ulcer Includes superficial wounds like cuts, blisters, or small open areas
Wound is painful
Ulcer is seen with reddish pinkish bed without slough or bruising
It's superficial and can appear as a blister, or shallow crater
Edema persists
Can become infected with pain and scant drainage
3. Characteristics of Full thickness skin loss
a stage 3 pres-
sure ulcer Injury extends through the dermis to the underlying fascia but does not extend
through the underlying fascia
Not always a deep wound depends on location of wound
Wound base is painful
Ulcer appears as a deep crater
Can have tunneling and undermining but not necessary to be considered a stage
3
Page 1
, Galen college of nursing NUR 155 exam 3 study set with complete solutions...
Galen college of nursing NUR 155 exam 3 study set
Study online at https://quizlet.com/_djvvi1
Drainage and infection are common
4. Characteristics of Has full thickness skin loss with visible muscle, tendon , and or bone present
a stage 4 pres-
sure ulcer Parts may be covered in slough or Eschar
Not usually painful due to necrosis
Deep pockets of infection may be present
Undermining and tunneling are usually present
Can be destruction , tissue necrosis , or damage to the muscle , tendon , and bone
5. Unstageable When slough or eschar interferes with assessment of depth of pressure injury and
pressure ulcer therefore staging is not possible
characteristics
6. Characteristics of Skin is intact
a suspected deep
tissue injury Patient had a purple or dark red or brown discoloration on the skin
Occurs when a pressure injury occurs underneath the skin so depth is unable to
be determined
Patient may have complained of pain in area before the discoloration occurred
The skin may have felt mushy , warm , or cool compared to surrounding areas of
skin
7. What are bony They are the end or a protrusion of bone where skin , muscle, and tissue is thin.
prominences? They are the highest risk areas of the body for developing pressure sores.
8.
Page 2
, Galen college of nursing NUR 155 exam 3 study set with complete solutions...
Galen college of nursing NUR 155 exam 3 study set
Study online at https://quizlet.com/_djvvi1
Full thickness in- An injury extending through the subcutaneous skin layers, muscles, and down to
jury the bone
9. What is blanch- It's whitening of the skin when pressure is applied. The result is brief temporary
ing? loss of blood flow.
Note} pressure injuries and ulcers are non-blanchable.
10. What is a Partial It's an injury to layers of the skin including the subcutaneous, dermis, and ,
thickness injury ? epidermis.
Note Partial thickness wounds are associated with stage 2 pressure injuries/
ulcers
11. What is debride- Within woundcare, debridement refers to the removal of adherent, dead or
ment? contaminated tissue from the wound.
12. serous drainage clear, watery
Made from plasma
Healing wounds
13. purulent Thick, yellow, green, tan, or brown drainage
drainage
In infected wounds
14. sanguineous Pink or pale red
drainage
Mix of serous and red blood fluid
Occurs in fresh wounds
15. Bright red mostly blood
Page 3
Galen college of nursing NUR 155 exam 3 study set
Study online at https://quizlet.com/_djvvi1
1. Characteristics of A nonblanchable area with redness
a stage 1 pres-
sure ulcer Has minor soft tissue swelling and warmth to area
Skin is intact
Normally reversible with appropriate nursing care
2. Characteristics of Partial thickness with loss of skin including the epidermis and or dermis
a stage 2 pres-
sure ulcer Includes superficial wounds like cuts, blisters, or small open areas
Wound is painful
Ulcer is seen with reddish pinkish bed without slough or bruising
It's superficial and can appear as a blister, or shallow crater
Edema persists
Can become infected with pain and scant drainage
3. Characteristics of Full thickness skin loss
a stage 3 pres-
sure ulcer Injury extends through the dermis to the underlying fascia but does not extend
through the underlying fascia
Not always a deep wound depends on location of wound
Wound base is painful
Ulcer appears as a deep crater
Can have tunneling and undermining but not necessary to be considered a stage
3
Page 1
, Galen college of nursing NUR 155 exam 3 study set with complete solutions...
Galen college of nursing NUR 155 exam 3 study set
Study online at https://quizlet.com/_djvvi1
Drainage and infection are common
4. Characteristics of Has full thickness skin loss with visible muscle, tendon , and or bone present
a stage 4 pres-
sure ulcer Parts may be covered in slough or Eschar
Not usually painful due to necrosis
Deep pockets of infection may be present
Undermining and tunneling are usually present
Can be destruction , tissue necrosis , or damage to the muscle , tendon , and bone
5. Unstageable When slough or eschar interferes with assessment of depth of pressure injury and
pressure ulcer therefore staging is not possible
characteristics
6. Characteristics of Skin is intact
a suspected deep
tissue injury Patient had a purple or dark red or brown discoloration on the skin
Occurs when a pressure injury occurs underneath the skin so depth is unable to
be determined
Patient may have complained of pain in area before the discoloration occurred
The skin may have felt mushy , warm , or cool compared to surrounding areas of
skin
7. What are bony They are the end or a protrusion of bone where skin , muscle, and tissue is thin.
prominences? They are the highest risk areas of the body for developing pressure sores.
8.
Page 2
, Galen college of nursing NUR 155 exam 3 study set with complete solutions...
Galen college of nursing NUR 155 exam 3 study set
Study online at https://quizlet.com/_djvvi1
Full thickness in- An injury extending through the subcutaneous skin layers, muscles, and down to
jury the bone
9. What is blanch- It's whitening of the skin when pressure is applied. The result is brief temporary
ing? loss of blood flow.
Note} pressure injuries and ulcers are non-blanchable.
10. What is a Partial It's an injury to layers of the skin including the subcutaneous, dermis, and ,
thickness injury ? epidermis.
Note Partial thickness wounds are associated with stage 2 pressure injuries/
ulcers
11. What is debride- Within woundcare, debridement refers to the removal of adherent, dead or
ment? contaminated tissue from the wound.
12. serous drainage clear, watery
Made from plasma
Healing wounds
13. purulent Thick, yellow, green, tan, or brown drainage
drainage
In infected wounds
14. sanguineous Pink or pale red
drainage
Mix of serous and red blood fluid
Occurs in fresh wounds
15. Bright red mostly blood
Page 3
