NSG-
300 Topic 8 Medication Administratio
xc xc xc xc
n
NSG-300 EXAM 2 Q AND A
whatxcplacesxcpatientsxcatxcriskxcforxcpressurexculcers/impairedxcskinxcintegrityxc-xcanswer--
pressurexcintensity,xcpressurexcduration,xctissuexctolerance,xcimpairedxcsensoryxcperception,xcimpairedxcmobility,xcalter
onxcinxcLOC,xcshear,xcfriction,xcmoisture
layersxcofxcthexcskinxc-xcanswer--epidermis,xcdermisxc(collagen)
body'sxcdefensesxcagainstxcinfectionxc-xcanswer--normalxcflora,xcinflammatoryxcresponse,xcimmunexcresponse
comprehensivexcwoundxcassessmentxc-xcanswer---
ongoingxcassessmentxcfromxctimexcofxcinjury,xcwoundxccare,xcanyxcconditionxcchanges,xcandxconxcscheduledxcbasis
-Importantxctoxcincludexccausexcofxcinjury,xchistoryxcofxcwound,xctreatment,xcdescription,xcresponsexctoxctherapy
-Bradenxcscale:xcassessesxcriskxcforxcpressure/skinxcinjuryxceveryxcshift
BradenxcScalexc-xcanswer--
assessesxcriskxcforxcdevelopingxcpressurexculcers;xcincludesxcpatient'sxcsensoryxcperception,xcmoisture,xcactivity,xcmob
y,xcnutrition,xcfrictionxcandxcshear;xcthexclowerxcthexcnumberxcthexchigherxcthexcrisk
>9=xcveryxchighxcrisk
10-12=xchighxcrisk
13-14=xcmoderatexcrisk
15-18=xcmildxcrisk
19-23=xcgenerallyxcnotxcatxcrisk
typexc1xculcersxc-xcanswer--skinxcisxcintactxcbutxcmayxcbexcredxcorxcpinkxcandxcwarmxctoxcthexctouch;xcnoxcblanching
-forxcPOC,xctherexcmayxcbexcnoxcnoticeablexcblanchingxcbutxcskinxccolorxcmayxcvary
typexc2xculcersxc-xcanswer--partial-thicknessxclossxcofxcdermis;xcshallowxcbrokenxcskin;xcred-pinkxcwoundxcbed
typexc3xculcersxc-xcanswer--full-thicknessxctissuexclossxcwithxcvisiblexcfatxc(subcutaneousxclayer);xcpale-
yellowxccolor;xcmayxcincludexcsloughxcbutxcdoesxcnotxcobstructxcviewxcofxcdepthxcofxcinjury
typexc4xculcersxc-xcanswer--full-
thicknessxctissuexclossxcwithxcexposedxcbone,xcmuscle,xcorxctendon.xcpossiblexctunnelingxcandxcundermining
unstageablexcpressurexculcerxc-xcanswer--basexcofxculcerxccoveredxcbyxcsloughxcand/
orxcescharxcinxcthexcwoundxcbedxcsoxcthexcdepthxcisxcunknown;xcexudate;
deepxctissuexcinjuryxc-xcanswer--Purplexcorxcmaroonxclocalizedxcareaxcofxcdiscoloredxcintactxcskinxcorxcblood-
filledxcblisterxcduexctoxcdamagexcofxcunderlyingxcsoftxctissuexcfromxcpressurexcand/orxcshear.
howxcshouldxcyouxccleanxcaxcwoundxc-xcanswer--fromxcleastxctoxcmostxccontaminated
escharxc-xcanswer--black,xcbrownxcorxcnecroticxctissuexcinxcwoundxcbed;xcneedsxctoxcbexcremovedxcbeforexchealing
1xc/
xc20
, NSG-
300 Topic 8 Medication Administratio
xc xc xc xc
sloughxc-xc n
answer--stringy pale-
xc
yellowishxctissuexcthatxclaysxcinxcthexcwoundxcbed;xcneedsxctoxcbexcremovedxcbeforexchealing
ifxcaxcpatientxchasxcslough,xceschar,xcandxcinfectiousxcexudatexcwhichxconexcwouldxcyouxcbexcmostxcconcernedxcaboutxc-
xcanswer--infectiousxcexudate
factorsxcinfluencingxcheatxcandxccoldxctolerancexc-xcanswer--Exposurexctime
Exposedxcskin
Temperature
Age
Perceptionxcofxcsensoryxcstimuli
assessmentxcforxcpressurexculcersxcincludesxc-xcanswer--location,xcstagingxc(depth),xctypexcandxc
%xcofxctissuexcinxcwoundxcbed,xcwoundxcdimensionsxc(includingxctunneling),xcexudatexcdescriptionxc(ifxcodorxcisxcpresent
andxcconditionxcofxcsurroundingxcskin
whyxcisxcdepthxcofxcanxculcerxcimportantxc-xcanswer--becausexcthexcwoundxchealsxcinside-out
granulationxctissuexc-xcanswer--
good,xcfreshxctissuexcthatxcformsxcduringxcthexchealingxcofxcaxcwoundxc(woundxcbedxcwillxcbexcred,xcmoist,xcandxcshiny)
Howxcdoesxcaxcpartialxcthicknessxcwoundxcheal?xc-xcanswer--byxcregenerationxc(scratchxcorxcabrasion)
-inflammatoryxcresponse:xcredness/swellingxctoxcareaxcwithxcmoderatexcserousxcexudate.xc1stxc24hrsxcafterxcwounding
-
epithelialxcproliferationxc(reproduction):xcstartsxcatxcwoundxcedgesxcandxcepidermalxccellsxcliningxcappendagesxc(quickxc
surfacing)
-
epithelialxcmigration:xcepithelialxccellsxconlyxcmigratexcinxcaxcmoistxcenvironment.xcinxcdryxcwound,xcthexccellsxcmovexcdow
cintoxcaxcmoistxclevelxcbeforexcresurfacingxccanxchappen
-reestablishmentxcofxcepidermalxclayers:xccellsxcslowlyxcestablishxcnormalxcthicknessxcandxcappearxcasxcdry,xcpinkxctissu
Howxcdoesxcaxcfullxcthicknessxcwoundxcheal?xc-xcanswer--byxcformingxcnewxctissue/
scarxcformation,xcwhichxctakesxclongerxc(pressurexculcers)
-hemostasis:xcinjuredxcvesselsxcconstrictxcandxcplateletsxcgatherxctoxcstopxcbleeding
-
inflammation:xcdamagedxctissuexcandxcmastxccellsxcsecretexchistaminexc(vasodilationxcofxcsurroundingxccapillariesxcand
movementxcofxcserumxcandxcWBCsxcintoxcdamagedxctissue)
-
proliferation:xcthexcvascularxcbedxcisxcreestablishedxc(granulationxctissue),xcthexcareaxcisxcfilledxcwithxcreplacementxctissu
c(collagen,xccontraction,xcandxcgranulationxctissue),xcandxcthexcsurfacexcisxcrepairedxc(epithelialization)
-
maturation:xcThexccollagenxcscarxccontinuesxctoxcreorganizexcandxcgainxcstrengthxcforxcseveralxcmonths.xcCollagenxcfibe
cundergoxcremodelingxcorxcreorganizationxcbeforexcassumingxctheirxcnormalxcappearance
primaryxcintentionxc-xcanswer--woundxcthatxcisxcclosed/
approximated;xclittlexctissuexcloss;xclowxcriskxcofxcinfection;xcquickxchealingxcwithxcnoxcscarxcusuallyxc(surgicalxcincision)
secondaryxcintentionxc-xcanswer--
axcwoundxcwithxclossxcofxctissue;xcwoundxcisxcnotxcapproximated;xchavexctoxchealxcfromxcthexcinside-
out;xcifxcscarringxcisxcsevere,xclossxcofxctissuexcfunctionxcmayxcbexcpermanentxc(pressurexculcers,xcsurgicalxcwoundxcthatx
asxctissuexcloss)
2xc/
xc20
, NSG-
300 Topic 8 Medication Administratio
xc xc xc xc
n
tertiaryxcintentionxc-xcanswer--
Woundxcthatxcisxcleftxcopenxcforxcseveralxcdays,xcthenxcwoundxcedgesxcarexcapproximated;xcdoctorxccanxcmonitorxcstatus
fxcwound
complicationsxcofxcwoundxchealingxc-xcanswer--hemorrhage,xcinfection,xcdehiscence,xcevisceration
CMSxc-xcanswer--
createdxcpolicyxcforxchospitalsxctoxcnoxclongerxcreceivexcadditionalxcreimbursementxcforxccarexcrelatedxctoxceightxcconditio
sxctoxcimprovexcqualityxcofxchealthxccare
signsxcandxcsymptomsxcofxcwoundxcinfectionxc-xcanswer--Contaminatedxcorxctraumaticxcwounds:xc2-3xcdays
Postxcopxcsurgicalxcwound:xc4-5xcdays
Fever,xctendernessxcandxcpainxcatxcwoundxcsite
ElevatedxcWBCxccount
Woundxcedgesxcappearxcinflamed
Drainagexcmayxcbexcpresent:xcodorousxcandxcpurulentxc(yellow,xcgreen,xcorxcbrown)
Dehiscencexc
Evisceration
whatxcisxcneededxcforxcwoundxchealingxc-xcanswer--proteinxc(albumin)
factorsxcinfluencingxcpressurexculcerxcformationxcandxcwoundxchealingxc-xcanswer---nutrition
-tissuexcperfusion
-infection
-age
-psychosocialxcimpactsxc(bodyxcimage)
whenxcshouldxcyouxcgivexcanxcanalgesicxc-xcanswer--atxcleastxc30xcminutesxcbeforexcremovingxcaxcwoundxcdressing
ScientificxcMethodxcnursingxc-xcanswer--•identifyxcthexcproblem,
•collectxcdata,
•formulatexcaxcquestionxcorxchypothesis,
•testxcthexcquestionxcorxchypothesis,xcand
evaluatexcresultsxcofxcthexctestxcorxcstudy.
Withxcdrainage,xcwhatxcshouldxcyouxcassessxc-xcanswer--
amount,xccolor,xcodor,xcandxcconsistencyxc(ifxcdrainagexcisxcpungentxcorxcstrong,xcsuspectxcinfection)
Thexcusexcofxcdiagnosticxcreasoningxcinvolvesxcaxcrigorousxcapproachxctoxcclinicalxcpracticexcandxcdemonstratesxcthatxcc
calxcthinkingxccannotxcbexcdonexc________xc-xcanswer--haphazardly
Jackson-Prattxcdrainxc-xcanswer--hollowxcbulb-likexcdevicexcusedxctoxccollectxcdrainage;xcneedsxcgentle-
negativexcsuctionxc(squeezexcbeforexcyouxctightenxcthexccap)
whatxcisxcthexcpurposexcofxcthexcnursingxcprocessxc-xcanswer--
toxcdxxcandxctxxchumanxcresponsesxctoxcactualxcorxcpotentialxchealthxcproblems.
nursingxcinterventionsxcforxcthexcpreventionxcofxcpressurexculcersxc-xcanswer---
skinxccarexcandxcmanagementxcofxcincontinencexc
-mechanicalxcloadingxcandxcsupportxcdevices
3xc/
xc20
300 Topic 8 Medication Administratio
xc xc xc xc
n
NSG-300 EXAM 2 Q AND A
whatxcplacesxcpatientsxcatxcriskxcforxcpressurexculcers/impairedxcskinxcintegrityxc-xcanswer--
pressurexcintensity,xcpressurexcduration,xctissuexctolerance,xcimpairedxcsensoryxcperception,xcimpairedxcmobility,xcalter
onxcinxcLOC,xcshear,xcfriction,xcmoisture
layersxcofxcthexcskinxc-xcanswer--epidermis,xcdermisxc(collagen)
body'sxcdefensesxcagainstxcinfectionxc-xcanswer--normalxcflora,xcinflammatoryxcresponse,xcimmunexcresponse
comprehensivexcwoundxcassessmentxc-xcanswer---
ongoingxcassessmentxcfromxctimexcofxcinjury,xcwoundxccare,xcanyxcconditionxcchanges,xcandxconxcscheduledxcbasis
-Importantxctoxcincludexccausexcofxcinjury,xchistoryxcofxcwound,xctreatment,xcdescription,xcresponsexctoxctherapy
-Bradenxcscale:xcassessesxcriskxcforxcpressure/skinxcinjuryxceveryxcshift
BradenxcScalexc-xcanswer--
assessesxcriskxcforxcdevelopingxcpressurexculcers;xcincludesxcpatient'sxcsensoryxcperception,xcmoisture,xcactivity,xcmob
y,xcnutrition,xcfrictionxcandxcshear;xcthexclowerxcthexcnumberxcthexchigherxcthexcrisk
>9=xcveryxchighxcrisk
10-12=xchighxcrisk
13-14=xcmoderatexcrisk
15-18=xcmildxcrisk
19-23=xcgenerallyxcnotxcatxcrisk
typexc1xculcersxc-xcanswer--skinxcisxcintactxcbutxcmayxcbexcredxcorxcpinkxcandxcwarmxctoxcthexctouch;xcnoxcblanching
-forxcPOC,xctherexcmayxcbexcnoxcnoticeablexcblanchingxcbutxcskinxccolorxcmayxcvary
typexc2xculcersxc-xcanswer--partial-thicknessxclossxcofxcdermis;xcshallowxcbrokenxcskin;xcred-pinkxcwoundxcbed
typexc3xculcersxc-xcanswer--full-thicknessxctissuexclossxcwithxcvisiblexcfatxc(subcutaneousxclayer);xcpale-
yellowxccolor;xcmayxcincludexcsloughxcbutxcdoesxcnotxcobstructxcviewxcofxcdepthxcofxcinjury
typexc4xculcersxc-xcanswer--full-
thicknessxctissuexclossxcwithxcexposedxcbone,xcmuscle,xcorxctendon.xcpossiblexctunnelingxcandxcundermining
unstageablexcpressurexculcerxc-xcanswer--basexcofxculcerxccoveredxcbyxcsloughxcand/
orxcescharxcinxcthexcwoundxcbedxcsoxcthexcdepthxcisxcunknown;xcexudate;
deepxctissuexcinjuryxc-xcanswer--Purplexcorxcmaroonxclocalizedxcareaxcofxcdiscoloredxcintactxcskinxcorxcblood-
filledxcblisterxcduexctoxcdamagexcofxcunderlyingxcsoftxctissuexcfromxcpressurexcand/orxcshear.
howxcshouldxcyouxccleanxcaxcwoundxc-xcanswer--fromxcleastxctoxcmostxccontaminated
escharxc-xcanswer--black,xcbrownxcorxcnecroticxctissuexcinxcwoundxcbed;xcneedsxctoxcbexcremovedxcbeforexchealing
1xc/
xc20
, NSG-
300 Topic 8 Medication Administratio
xc xc xc xc
sloughxc-xc n
answer--stringy pale-
xc
yellowishxctissuexcthatxclaysxcinxcthexcwoundxcbed;xcneedsxctoxcbexcremovedxcbeforexchealing
ifxcaxcpatientxchasxcslough,xceschar,xcandxcinfectiousxcexudatexcwhichxconexcwouldxcyouxcbexcmostxcconcernedxcaboutxc-
xcanswer--infectiousxcexudate
factorsxcinfluencingxcheatxcandxccoldxctolerancexc-xcanswer--Exposurexctime
Exposedxcskin
Temperature
Age
Perceptionxcofxcsensoryxcstimuli
assessmentxcforxcpressurexculcersxcincludesxc-xcanswer--location,xcstagingxc(depth),xctypexcandxc
%xcofxctissuexcinxcwoundxcbed,xcwoundxcdimensionsxc(includingxctunneling),xcexudatexcdescriptionxc(ifxcodorxcisxcpresent
andxcconditionxcofxcsurroundingxcskin
whyxcisxcdepthxcofxcanxculcerxcimportantxc-xcanswer--becausexcthexcwoundxchealsxcinside-out
granulationxctissuexc-xcanswer--
good,xcfreshxctissuexcthatxcformsxcduringxcthexchealingxcofxcaxcwoundxc(woundxcbedxcwillxcbexcred,xcmoist,xcandxcshiny)
Howxcdoesxcaxcpartialxcthicknessxcwoundxcheal?xc-xcanswer--byxcregenerationxc(scratchxcorxcabrasion)
-inflammatoryxcresponse:xcredness/swellingxctoxcareaxcwithxcmoderatexcserousxcexudate.xc1stxc24hrsxcafterxcwounding
-
epithelialxcproliferationxc(reproduction):xcstartsxcatxcwoundxcedgesxcandxcepidermalxccellsxcliningxcappendagesxc(quickxc
surfacing)
-
epithelialxcmigration:xcepithelialxccellsxconlyxcmigratexcinxcaxcmoistxcenvironment.xcinxcdryxcwound,xcthexccellsxcmovexcdow
cintoxcaxcmoistxclevelxcbeforexcresurfacingxccanxchappen
-reestablishmentxcofxcepidermalxclayers:xccellsxcslowlyxcestablishxcnormalxcthicknessxcandxcappearxcasxcdry,xcpinkxctissu
Howxcdoesxcaxcfullxcthicknessxcwoundxcheal?xc-xcanswer--byxcformingxcnewxctissue/
scarxcformation,xcwhichxctakesxclongerxc(pressurexculcers)
-hemostasis:xcinjuredxcvesselsxcconstrictxcandxcplateletsxcgatherxctoxcstopxcbleeding
-
inflammation:xcdamagedxctissuexcandxcmastxccellsxcsecretexchistaminexc(vasodilationxcofxcsurroundingxccapillariesxcand
movementxcofxcserumxcandxcWBCsxcintoxcdamagedxctissue)
-
proliferation:xcthexcvascularxcbedxcisxcreestablishedxc(granulationxctissue),xcthexcareaxcisxcfilledxcwithxcreplacementxctissu
c(collagen,xccontraction,xcandxcgranulationxctissue),xcandxcthexcsurfacexcisxcrepairedxc(epithelialization)
-
maturation:xcThexccollagenxcscarxccontinuesxctoxcreorganizexcandxcgainxcstrengthxcforxcseveralxcmonths.xcCollagenxcfibe
cundergoxcremodelingxcorxcreorganizationxcbeforexcassumingxctheirxcnormalxcappearance
primaryxcintentionxc-xcanswer--woundxcthatxcisxcclosed/
approximated;xclittlexctissuexcloss;xclowxcriskxcofxcinfection;xcquickxchealingxcwithxcnoxcscarxcusuallyxc(surgicalxcincision)
secondaryxcintentionxc-xcanswer--
axcwoundxcwithxclossxcofxctissue;xcwoundxcisxcnotxcapproximated;xchavexctoxchealxcfromxcthexcinside-
out;xcifxcscarringxcisxcsevere,xclossxcofxctissuexcfunctionxcmayxcbexcpermanentxc(pressurexculcers,xcsurgicalxcwoundxcthatx
asxctissuexcloss)
2xc/
xc20
, NSG-
300 Topic 8 Medication Administratio
xc xc xc xc
n
tertiaryxcintentionxc-xcanswer--
Woundxcthatxcisxcleftxcopenxcforxcseveralxcdays,xcthenxcwoundxcedgesxcarexcapproximated;xcdoctorxccanxcmonitorxcstatus
fxcwound
complicationsxcofxcwoundxchealingxc-xcanswer--hemorrhage,xcinfection,xcdehiscence,xcevisceration
CMSxc-xcanswer--
createdxcpolicyxcforxchospitalsxctoxcnoxclongerxcreceivexcadditionalxcreimbursementxcforxccarexcrelatedxctoxceightxcconditio
sxctoxcimprovexcqualityxcofxchealthxccare
signsxcandxcsymptomsxcofxcwoundxcinfectionxc-xcanswer--Contaminatedxcorxctraumaticxcwounds:xc2-3xcdays
Postxcopxcsurgicalxcwound:xc4-5xcdays
Fever,xctendernessxcandxcpainxcatxcwoundxcsite
ElevatedxcWBCxccount
Woundxcedgesxcappearxcinflamed
Drainagexcmayxcbexcpresent:xcodorousxcandxcpurulentxc(yellow,xcgreen,xcorxcbrown)
Dehiscencexc
Evisceration
whatxcisxcneededxcforxcwoundxchealingxc-xcanswer--proteinxc(albumin)
factorsxcinfluencingxcpressurexculcerxcformationxcandxcwoundxchealingxc-xcanswer---nutrition
-tissuexcperfusion
-infection
-age
-psychosocialxcimpactsxc(bodyxcimage)
whenxcshouldxcyouxcgivexcanxcanalgesicxc-xcanswer--atxcleastxc30xcminutesxcbeforexcremovingxcaxcwoundxcdressing
ScientificxcMethodxcnursingxc-xcanswer--•identifyxcthexcproblem,
•collectxcdata,
•formulatexcaxcquestionxcorxchypothesis,
•testxcthexcquestionxcorxchypothesis,xcand
evaluatexcresultsxcofxcthexctestxcorxcstudy.
Withxcdrainage,xcwhatxcshouldxcyouxcassessxc-xcanswer--
amount,xccolor,xcodor,xcandxcconsistencyxc(ifxcdrainagexcisxcpungentxcorxcstrong,xcsuspectxcinfection)
Thexcusexcofxcdiagnosticxcreasoningxcinvolvesxcaxcrigorousxcapproachxctoxcclinicalxcpracticexcandxcdemonstratesxcthatxcc
calxcthinkingxccannotxcbexcdonexc________xc-xcanswer--haphazardly
Jackson-Prattxcdrainxc-xcanswer--hollowxcbulb-likexcdevicexcusedxctoxccollectxcdrainage;xcneedsxcgentle-
negativexcsuctionxc(squeezexcbeforexcyouxctightenxcthexccap)
whatxcisxcthexcpurposexcofxcthexcnursingxcprocessxc-xcanswer--
toxcdxxcandxctxxchumanxcresponsesxctoxcactualxcorxcpotentialxchealthxcproblems.
nursingxcinterventionsxcforxcthexcpreventionxcofxcpressurexculcersxc-xcanswer---
skinxccarexcandxcmanagementxcofxcincontinencexc
-mechanicalxcloadingxcandxcsupportxcdevices
3xc/
xc20
