Fundamentals Midterm
BSN-8 Midterm Study Highlights
Braden Scale (know what it is, how to screen a patient for skin breakdown)
Rates a client's risk for alterations in tissue integrity using 6 categories:
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
Lowest: 6
Highest: 23
The lower the score, the greater the risk for alterations in skin and tissue integrity.
Pressure Injuries (Wound Care, Braden Scale, Staging, Prevention, Nursing Assessment, Application of
the Nursing Process).
Stages of Pressure I, II, III, IV & Unstageable
Injury
Stage I Non-blanchable Erythema:
The skin is intact, red but unbroken. Localized redness in lightly
pigmented skin does not blanch (turn light with fingertip pressure).
Dark skin appears darker but does not blanch. May have changes in
sensation, temperature, or firmness.
Stage 1 pressure injury presents with intact, reddened skin. There is no
loss of skin or drainage associated with this stage of pressure injury.
, Stage 1: A stage 1 pressure injury presents with intact, non-blanchable,
redness of the skin. There is no loss of skin or drainage associated with
this stage of pressure injury
Stage II Partial thickness skin loss:
Loss of epidermis and exposed dermis. Superficial ulcer looks
shallow like an abrasion or open blister with a red-pink
wound bed. No visible fat or deeper tissue.
A stage 2 pressure injury may also present as a ruptured serum-filled
blister.
Stage III Full-thickness skin loss:
Visible adipose tissue with possible granulation
tissue and epibole. Some slough, and eschar present.
No exposed muscle, tendons, ligaments, cartilage, or
bones. Possible tunneling and undermining.
Stage IV Full thickness skin/tissue loss
PI involves all skin layers and extends into supporting tissue.
Exposes muscle, tendon, or bone, and may show slough
(stringy matter attached to wound bed) or eschar (black or
brown necrotic tissue), rolled edges, and tunneling.
BSN-8 Midterm Study Highlights
Braden Scale (know what it is, how to screen a patient for skin breakdown)
Rates a client's risk for alterations in tissue integrity using 6 categories:
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
Lowest: 6
Highest: 23
The lower the score, the greater the risk for alterations in skin and tissue integrity.
Pressure Injuries (Wound Care, Braden Scale, Staging, Prevention, Nursing Assessment, Application of
the Nursing Process).
Stages of Pressure I, II, III, IV & Unstageable
Injury
Stage I Non-blanchable Erythema:
The skin is intact, red but unbroken. Localized redness in lightly
pigmented skin does not blanch (turn light with fingertip pressure).
Dark skin appears darker but does not blanch. May have changes in
sensation, temperature, or firmness.
Stage 1 pressure injury presents with intact, reddened skin. There is no
loss of skin or drainage associated with this stage of pressure injury.
, Stage 1: A stage 1 pressure injury presents with intact, non-blanchable,
redness of the skin. There is no loss of skin or drainage associated with
this stage of pressure injury
Stage II Partial thickness skin loss:
Loss of epidermis and exposed dermis. Superficial ulcer looks
shallow like an abrasion or open blister with a red-pink
wound bed. No visible fat or deeper tissue.
A stage 2 pressure injury may also present as a ruptured serum-filled
blister.
Stage III Full-thickness skin loss:
Visible adipose tissue with possible granulation
tissue and epibole. Some slough, and eschar present.
No exposed muscle, tendons, ligaments, cartilage, or
bones. Possible tunneling and undermining.
Stage IV Full thickness skin/tissue loss
PI involves all skin layers and extends into supporting tissue.
Exposes muscle, tendon, or bone, and may show slough
(stringy matter attached to wound bed) or eschar (black or
brown necrotic tissue), rolled edges, and tunneling.
