Skin Integrity

  1. In there is a red spot over a bony prominence that does not blanch, what stage ulcer is this?
    Stage 1
  2. If you find an ulcer that has gone through the dermis and epidermis What stage ulcer is this?
    Stage 2
  3. If you find an ulcer that tunnels and you can see bone and tendons, What stage ulcer is this?
    Stage 4
  4. If you find an ulcer that has full thickness tissue loss and can see fat, What stage is this?
    Stage 3
  5. 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
  6. What is hemorrhagic and what could cause it?
    • Excessive bleeding
    • Dislodging of a clot
  7. Hematoma
    • Bleeding under the skin.
    • *Circle the border... look for expansion
  8. Dehiscence
    A wound that starts to heal at top and bottom but reopens in the middle
  9. Evisceration
    When organs come out of a wound
  10. A wound has yellow and watery fluid coming out... What kind of drainage is this?
  11. A wound has pus coming out (white yellow or green)? What kind of drainage is this?
  12. A wound has bloody drainage. What is this from? And What kind of drainage is this?
    • From damage on the capillary level
    • Sanguienous
  13. If there is pink drainage, what kind drainage
  14. 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
  15. In the Norton scale a score 14 or less indicates what?
    Pressure ulcer development
  16. When should the patient have had a tetanus exam?
    Within the last 5 years
  17. What are 3 common sites of pressure ulcers
    • above the buttocks
    • Back of the head
    • Heels
  18. What is a normal WBC count?
    4500- 10000
  19. When there is an infection, What cell is high?
  20. What protien helps promote healing?
  21. How often should you turn a patient with pressure ulcers?
    Every 2 hours
  22. Tegaderm is an example of what kind of wound dressing?
    What stage ulcer would you use this on?
    • Transparent film
    • Stage 2
    • it is airtight and holds in moisture while minimizing infection
  23. 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
  24. 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
  25. Clear absorbant acrylic is what?
    • Dermabond
    • Clear liquid band aid used instead of sutures
  26. What is the purpose of polyurathane foam?
    Used around the site of a wound to collect excess drainage
  27. What is alginate?
    Seaweed and then a dry dressing on top of that?
  28. Chemical debridment
    Uses topical enzyme or maggots to get rid of dead tissue
  29. Surgical debridment
    the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument
  30. Mechanical debridment
    want the dressing to adhere to the wound and pull dead tissue off.
  31. What examples of dry heat?
    • heat packs
    • Hot water bottle
    • electric pads
  32. Moist heat
    • compresses
    • soaks
    • Sitz Baths
  33. 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
  34. What are some examples of dry cold
    • Ice bags
    • Ice packs
  35. What are some examples of moist cold?
    • compress
    • cool bath
Card Set
Skin Integrity
drexel skin integrity