Nursing Final Exam: Taylor Fundamentals of Nursing, Edition 7 [100% verified]

Nursing Final Exam: Taylor Fundamentals of Nursing, Edition 7 [100% verified] Pressure ulcer: medical name *Ans* decubitus ulcer Stages of a decubitus ulcer: Stage II *Ans* Partial-thickness skin loss involving the epidermis and the dermis. the ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Stages of a decubitus ulcer: Stage III *Ans* Full thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stages of a decubitus ulcer: Stage IV *Ans* Full thickness tissue loss with distruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material) or slough (tan, yellow, or green scab-like material) Stages of a decubitus ulcer: Unstageable *Ans* Ulcers whose stage cannot be determined because eschar or slough obscures the wound Stages of wound healing *Ans* 1. Inflammatory (initial) -immediate phase, lasts about 3 days -increased blood supply and phagocytosis (delivers oxygen, wbcs, and nutrient to the wound to support healing) -control bleeding for clot formation 2. Proliferative (granulation) -second phase -fibroblasts synthesize collagen -formation of granulation tissue 3. Maturation and Remodeling -continued granulation and strengthening of tissue -scar formation Factor that affect wound healing *Ans* Factors that affect wound healing include: age, loss of skin turgor, skin fragility, decreased peripheral circulation and oxygenation, slower tissue regeneration, malnutrition, decreased collagen, immune sys. impairment, medications, obesity, stress, smoking, and wound stress, among others. Principles of wound care: (3 answers) *Ans* Assessmen