Skin Integrity

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In there is a red spot over a bony prominence that does not blanch, what stage ulcer is this?

Stage 1
If you find an ulcer that has gone through the dermis and epidermis What stage ulcer is this?

Stage 2
If you find an ulcer that tunnels and you can see bone and tendons, What stage ulcer is this?

Stage 4
If you find an ulcer that has full thickness tissue loss and can see fat, What stage is this?

Stage 3
What would you do nutritionally to encourage wound healing?
- Vitamin C- helps with collagen synthesis
- Vitamin E
- Zinc
- Maintain Hydration Status
- Protein before any surgery
What is hemorrhagic and what could cause it?
- Excessive bleeding
- Dislodging of a clot
Hematoma
- Bleeding under the skin.
- *Circle the border... look for expansion
Dehiscence

A wound that starts to heal at top and bottom but reopens in the middle
Evisceration

When organs come out of a wound
A wound has yellow and watery fluid coming out... What kind of drainage is this?

Serous
A wound has pus coming out (white yellow or green)? What kind of drainage is this?

Purulant
A wound has bloody drainage. What is this from? And What kind of drainage is this?
- From damage on the capillary level
- Sanguienous
If there is pink drainage, what kind drainage

Serosanguinous
What are some nursing diagnosis' for skin integrity and wound care?

•Risk for infection•Imbalanced nutrition: less than body requirements•Acute or chronic pain•Impaired physical mobility•Impaired skin integrity•Risk for impaired skin integrity•Ineffective tissue perfusion•Impaired tissue integrity
In the Norton scale a score 14 or less indicates what?

Pressure ulcer development
When should the patient have had a tetanus exam?

Within the last 5 years
What are 3 common sites of pressure ulcers
- above the buttocks
- Back of the head
- Heels
What is a normal WBC count?

4500- 10000
When there is an infection, What cell is high?

Leukocytes
What protien helps promote healing?

Albumin
How often should you turn a patient with pressure ulcers?

Every 2 hours
Tegaderm is an example of what kind of wound dressing?
What stage ulcer would you use this on?
Why?
- Transparent film
- Stage 2
- it is airtight and holds in moisture while minimizing infection
What is the purpose of an impregnated nonadherent wound dressing?

It is used for a wound that is draining alot. It is infused with saline to help drain moisture
What is an example of a hydrocolloid dressing?
- DuoDerm
- Meant to stay in place 3-5 days
- Meant to absorb fluid and drainage but also keep it moist
Clear absorbant acrylic is what?
- Dermabond
- Clear liquid band aid used instead of sutures
What is the purpose of polyurathane foam?

Used around the site of a wound to collect excess drainage
What is alginate?

Seaweed and then a dry dressing on top of that?
Chemical debridment

Uses topical enzyme or maggots to get rid of dead tissue
Surgical debridment

the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument
Mechanical debridment

want the dressing to adhere to the wound and pull dead tissue off.
What examples of dry heat?
- heat packs
- Hot water bottle
- electric pads
Moist heat
- compresses
- soaks
- Sitz Baths
A dehydrated patient has a wound What would be the best application of heat.... Moist or dry?

Warm moist heat does not promote sweating or insensible fluid loss
What are some examples of dry cold
- Ice bags
- Ice packs
What are some examples of moist cold?
- compress
- cool bath

Author

NurseNatalie

53336

Card Set

Skin Integrity

Description

drexel skin integrity

Updated

2010-12-05T00:00:18Z

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