Skin Integrity

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Nursing
April 11, 2008

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when charting about drainagefrom wound chart:: amt color odor and consistency
eviscerations: when a wound busts open AND organs come out! eww
Risk for _____ is greatest in the first 48 hours post op.: Hemorrhage
purulent: thicker than serous and contains pus!
unintentional wounds occur: accidentally.
Causes of Hemorrhage:: dislodged clot, slipped suture, or erosion of blood vessel
you can clean wounds with gentle ______?: Irrigation
Treatment of Stage 2: Saline and occlusive dressing
Treatment of stage 3: damp to damp dressing and surgical intervention (keep it clean and moist)
Nurse can press down on potential pressure ulcer...if it stays red (doesnt turn white for a moment)...: You know you have a Stage 1 pressure ulcer.
inflammatory phase lasts...: 3-6 days
Shearing is rubbing how many ways?: 2 ways
Poor skin turgur is manifested by: dehydration
Five layers to be aware of when considering pressure ulcers: Epidermis, Dermis, Sub Q, Muscle tissue, and bone
The three phases of wound healing: inflammation, proliferation, and maturation
Maturation phase: day 21- to up to 2 years...collagen is remodeled, would becomes stronger and more like surrounding tissue, and scar formation
Stage 4 pressure ulcer details: tissue necrosis with damage to muscle, bone,, tendons, or joint capsules, full thinkness skin loss, cover with non-adherent dressing
Serous: consists primarily of serum
Another name for drainage: Exudate
Friction is rubbing how many ways?: 1 way
Proliferative phase: day 3- day 21, fibroblasts synthesize collagen, capillaries grow across wound, granulation tissue forms
What score is high risk for Braden Scale?: less than 18 is high risk
Skin _____ usually occurs 2-7 days after injury.: infection
after pressure ulcer developement...if redness disappears...?: no damage is done.
Fatty tissue has small amount of _______.: circulation.
Most common sights for pressure ulcers: sacrum, coccys, calcaneous (heals)
hemostasis=: bleeding stops! during inflammatory stage
after pressure ulcer developement...if redness remains...?: damage has been done.
Treatment for Stage 4 PU: Change dressing every 8-12 hours AND may require skin grafts
Skin should be: warm and dry
during the inflammatory phase...what is deposited?: Fibrin
Serosangineous: clear and blood tinged drainage
presence of abnormal pathways includes:: sinus tract, tunneling, or undermining (caves)
dehiscence is: when a wound busts open but nothing (organs) come out
People at risk for dehiscence and evisceration: obese, malnourished, infected wounds, excessive coughing, vomitting, straining
Stage 2 P.U. details: Affects epidermis and dermis, partial thickness skin loss, abrasion blister and shallow crater
Skin assessment includes: color, texture, temp, turgur, moisture, sensation, vascularity, presence of lesions...
Good score for braden scale: 23 or higher
4 ways that wounds are classified according to how they are acquired...: Clean, clean-contaminated, Contaminated, or dirty or infected..
Reactive hyperemia: is when skin becomes bright red.
Exudate: fluid and cells that has escaped from the blood vessels during inflammatory process
Way to measure skin risk: Braden Scale
two types of wounds: intentional and unintentional
Pressure ulcers are: the most common type of skin disruption and most preventable
Stage 3 p.u. details: tissue necrosis of Sub Q layer, full thickness skin loss, deep crater
Debribement can include using...: Sharps or enzymes (chemicals)
Other names for pressure ulcers...: decubitous ulcer, pressure sores, or bedsores
This is due to localized ischemia (cut off of blood supply): cause of pressure ulcers
sanguinous: consists of large amts of RBCs
Types of drains:: penrose, t-tube, jackson-pratt, hemovac, and Wound Vac
Intentional wounds: wound occurs during therapy
Charactoristics of Stage 1 P.U.: affects the epidermis, and non blanchable skin

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Number of cards 52