NSG 100 Exam V3
• unstageable wound: -full thickness tissue loss in which actual depth of the ulceris
completely obscured by slough and/or eschar in the wound bed
• suspected deep tissue injury:
-Purple or maroon localized area of discoloredintact skin or blood-filled blister due to damage
of underlying soft tissue from pressure and/or shear.
-The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer orcooler as
compared to adjacent tissue
• documentation of pressure injuries:
-Location of injury related to bony promi-nence
-Size in centimeters: length, width, depth
-Presence of undermining or sinus tracts
-Stage
-Color of wound bed, location of necrosis or eschar
-Condition of wound margins
-Integrity of surrounding skin
-Clinical signs of infection
-Patient complaints of pain, discomfort
-Signs of infection
• Cleaning a Pressure Ulcer: Clean with each dressing change.Use careful, gentle motions
to minimize trauma.
Use 0.9% normal saline solution to irrigate and clean the ulcer.Report any drainage or necrotic
tissue.
• wound exudate: describe the amount, color, consistency, and odor of wounddrainage
• exudate: fluid rich in protein and cellular elements that oozes out of bloodvessels due to
inflammation.
• serous: clear, thin and watery
• purulent: opaque, pus, thick, milky consistency
• serosanguinous: both blood and serum(liquid part of the blood) yellowish withsmall
amount of blood.
• sanguinoeous: bloody drainage
, • nursing diagnoses for pressure ulcers:: -Impaired Skin Integrity, Risk forSkin Integrity,
Impaired
Infection, Risk for
Imbalanced Nutrition: Less Than Body RequirementsCompromised Human Dignity, Risk for
Situational Low Self-Esteem
• goals for patients w/pressure ulcers: -Patient who is immobile or on bedrestwill be
repositioned every 2 hours
-Mobile patient will maintain or improve activity levels
-Patient will report any alterations
-Patient will articulate importance of maintaining adequate nutrition, hydration
-Patient will describe measures to protect, heal tissue
• interventions for patients with impaired skin integrity:: -Conduct systematicskin inspection
at least once a day
-Clean skin at time of soiling and at routine intervals
-Minimize environmental factors leading to skin drying
-Avoid massaging over bony prominences
-Minimize skin exposure to moisture from incontinence, perspiration, or wounddrainage
-Minimize skin injury due to friction, shearing forces
-Proper positioning, transferring, turning can eliminate most shear injuries
-For patient who is immobile or on bedrest, provide interventions against pressure,friction,
shear
-Reposition at-risk patient at least every 2 hours, using written schedule
-Use positioning devices to protect bony prominences
-For immobile patient, use devices to relieve pressure on heels
-Avoid placing patient in side-lying position directly on trochanter
-Maintain head of bed at lowest elevation consistent with patient's condition
-Use assistive devices to move patient in bed who cannot help with transfers,position changes
-For chairbound patient:
-Use pressure-reducing devices
-Avoid uninterrupted sitting
-Reposition patient every hour
• unstageable wound: -full thickness tissue loss in which actual depth of the ulceris
completely obscured by slough and/or eschar in the wound bed
• suspected deep tissue injury:
-Purple or maroon localized area of discoloredintact skin or blood-filled blister due to damage
of underlying soft tissue from pressure and/or shear.
-The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer orcooler as
compared to adjacent tissue
• documentation of pressure injuries:
-Location of injury related to bony promi-nence
-Size in centimeters: length, width, depth
-Presence of undermining or sinus tracts
-Stage
-Color of wound bed, location of necrosis or eschar
-Condition of wound margins
-Integrity of surrounding skin
-Clinical signs of infection
-Patient complaints of pain, discomfort
-Signs of infection
• Cleaning a Pressure Ulcer: Clean with each dressing change.Use careful, gentle motions
to minimize trauma.
Use 0.9% normal saline solution to irrigate and clean the ulcer.Report any drainage or necrotic
tissue.
• wound exudate: describe the amount, color, consistency, and odor of wounddrainage
• exudate: fluid rich in protein and cellular elements that oozes out of bloodvessels due to
inflammation.
• serous: clear, thin and watery
• purulent: opaque, pus, thick, milky consistency
• serosanguinous: both blood and serum(liquid part of the blood) yellowish withsmall
amount of blood.
• sanguinoeous: bloody drainage
, • nursing diagnoses for pressure ulcers:: -Impaired Skin Integrity, Risk forSkin Integrity,
Impaired
Infection, Risk for
Imbalanced Nutrition: Less Than Body RequirementsCompromised Human Dignity, Risk for
Situational Low Self-Esteem
• goals for patients w/pressure ulcers: -Patient who is immobile or on bedrestwill be
repositioned every 2 hours
-Mobile patient will maintain or improve activity levels
-Patient will report any alterations
-Patient will articulate importance of maintaining adequate nutrition, hydration
-Patient will describe measures to protect, heal tissue
• interventions for patients with impaired skin integrity:: -Conduct systematicskin inspection
at least once a day
-Clean skin at time of soiling and at routine intervals
-Minimize environmental factors leading to skin drying
-Avoid massaging over bony prominences
-Minimize skin exposure to moisture from incontinence, perspiration, or wounddrainage
-Minimize skin injury due to friction, shearing forces
-Proper positioning, transferring, turning can eliminate most shear injuries
-For patient who is immobile or on bedrest, provide interventions against pressure,friction,
shear
-Reposition at-risk patient at least every 2 hours, using written schedule
-Use positioning devices to protect bony prominences
-For immobile patient, use devices to relieve pressure on heels
-Avoid placing patient in side-lying position directly on trochanter
-Maintain head of bed at lowest elevation consistent with patient's condition
-Use assistive devices to move patient in bed who cannot help with transfers,position changes
-For chairbound patient:
-Use pressure-reducing devices
-Avoid uninterrupted sitting
-Reposition patient every hour
