NR 224 Ch 48 Study Guide(2020/2021): CHAMBERLAIN COLLEGE OF NURSING (VERIFIED ANSWERS, DOWNLOAD TO SCORE A)

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1. Epidermis a. E. top layer of the skin. 2. Dermis a. F. inner layer of the skin that provides tensile strength and mechanical support. 3. Collagen a. A. tough, fibrous protein. 4. Pressure ul... cer a. B. localized injury to the skin and underlying tissue over a body prominence. 5. Blanching a. D. normal red tones of light-skinned patients are absent. 6. Darkly pigmented skin a. C. does not blanch. 7. Identify the pressure factors that contribute to pressure ulcer development. a. Pressure intensity. b. Pressure duration. c. Tissue tolerance. 8. Identify the risk factors that predispose a patient to pressure ulcer formation. a. Impaired sensory perception. b. Impaired mobility. c. Altered LOC. d. Shear. e. Friction. f. Moisture. 9. Staging systems for pressure ulcers are based on the depth of tissue destroyed. Briefly describe each stage. a. Stage I: skin is intact, nonblanchable. May have discoloration, warmth, edema, hardness, and pain at site. Adjacent tissues may be soft, firm, or cooler. b. Stage II: Partial-thickness loss of tissues. Open with red-pink wound bed without slough. May have serum or serosanguineous filled blister. Can appear shiny, dry and/or shallow. c. Stage III: Full-thickness loss of tissues. Subcutaneous fat is visible. d. Stage IV: Full-thickness loss of tissues. Bone, tendon, muscles, subcutaneous fat may be visible. Slough or eschar may be present in wound bed. Can lead to osteomyelitis or osteitis. Define the following terms related to wound [Show More]

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