Skin Integrity
Nursing
April 11, 2008
April 11, 2008
Terms
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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