Pressure Ulcer Stages and Nursing Interventions, Exams of Advanced Education

Download Pressure Ulcer Stages and Nursing Interventions and more Exams Advanced Education in PDF only on Docsity! Hondros Nursing Nur 150: Exam 2 Stage 1 pressure ulcer - Answer- Intact skin with nonblanchable redness Stage 2 pressure ulcer - Answer- Partial loss of dermis. Shallow open ulcer, usually shiny, or dry. Red-pink wound bed without sloughing or bruising. Stage 3 pressure ulcer - Answer- Full thickness tissue loss, subcutaneous fat may be visible. Possible undermining and tunneling. Stage 4 pressure ulcer - Answer- Full thickness tissue loss with exposed bone, tendon,or muscle. Slough or eschar may be present as well as undermining and tunneling. Unstageable pressure ulcer - Answer- Full thickness tissue loss, wound base covered by slough and eschar therefor dull depth cannot be determined. Slough - Answer- Fibrous tissue in wound bed that can be yellow, tan, gray, green, or brown. Nursing interventions to prevent pressure unlcers - Answer- Reposition bed bound pt every two hours, instruct pt in wheelchair to shift their weight every hour. Use of cushions and barrier cream. Manage moisture, optimize nutrition and hydration. Cognition - Answer- All the processes involved in human thought External nutrition - Answer- Nutrition support via tube feedings Parenteral nutrition - Answer- Nutrition supplied intravenously DRI - Answer- Refers to a set of nutritional based values that serve for both assessing and planning diets Three ways to confirm proper NG placement - Answer- Chest x-ray, PH test gastric contents, air bolus. With tube feeding what must be monitored daily - Answer- I/O, daily weight, daily labs