NR 224 EXAM 2
CHPT 48 SKIN INTEGRITY AND WOUND CARE
, NR 224 EXAM 2
CHPT 48 SKIN INTEGRITY AND WOUND CARE
Pressure ulcers localized injury on bony prominence from shear (force parallel to skin) and.or friction(dragged), moisture
Ischemia
Blanching -> red tones are absent (not in dark skin patients)
Older adults, decreased consciousness @ high risk
Urine maceration & skin breakdown
Use incontinence cleanser, dry skin , moisture barrier ointment
contusion : close wound
laceration : jagged irregular edges
serous : watery , clear
serasangious : watery, pink, blood
tinged frank : fresh blood
purelent : infection , thick , WBC, bacteria, tissue debri , odor
Skeleton balance suspension traction shift weight while immobile, Bucts
traction restriction of movement (hip fracture)
Halo brace can ambulate with halo brace
Nutrition
Observation of skin
Ulcers (up walking, position changing)
Lifting
Clean skin/continence care
Elevate the heels
Risk assessment
, Support surfaces for even distributions
Stage 1: nonblanchable redness, intact skin (don’t massage)
Stage II: Partial thickness , skin loss (epidermis & dermis), blister, w/o slough, abrasion (ex: shallow open reddish w/o
slough (scab like) on heel of foot)
Stage III: full thickness tissue loss with fat, slough may be present, drainage and infection may be present , purulent
discharge (thick milky), full had to toe
Stage IV: full thickness tissue with exposed bone, muscle, or tendon , escare (black), HEAL BY SCAR FORMATION !
Unstageable : depth is unknown, completely obscured by slough (yellow, tan , green) or escar (tan to black), can be a
III or a IV, suspected deep tissure injury, purple or marron, localized, intact skin, blood filled blister
Assess the type of tissue amount, appearance(color), viable/nonviable tissue, granulation tissue (red moist new blood
vessels healing) , slough must be removed by skilled tech or wound dressing
Protein is important for skin (wound healing)
albumin level 3.5 to 5 (less than 3.5 means lacking protein skin breakdown)
hydrogel/hydrocolloid dressing (moisture) provided for healing
low air therapy units decrease pressure
Q2 turns!
Healing:
CHPT 48 SKIN INTEGRITY AND WOUND CARE
, NR 224 EXAM 2
CHPT 48 SKIN INTEGRITY AND WOUND CARE
Pressure ulcers localized injury on bony prominence from shear (force parallel to skin) and.or friction(dragged), moisture
Ischemia
Blanching -> red tones are absent (not in dark skin patients)
Older adults, decreased consciousness @ high risk
Urine maceration & skin breakdown
Use incontinence cleanser, dry skin , moisture barrier ointment
contusion : close wound
laceration : jagged irregular edges
serous : watery , clear
serasangious : watery, pink, blood
tinged frank : fresh blood
purelent : infection , thick , WBC, bacteria, tissue debri , odor
Skeleton balance suspension traction shift weight while immobile, Bucts
traction restriction of movement (hip fracture)
Halo brace can ambulate with halo brace
Nutrition
Observation of skin
Ulcers (up walking, position changing)
Lifting
Clean skin/continence care
Elevate the heels
Risk assessment
, Support surfaces for even distributions
Stage 1: nonblanchable redness, intact skin (don’t massage)
Stage II: Partial thickness , skin loss (epidermis & dermis), blister, w/o slough, abrasion (ex: shallow open reddish w/o
slough (scab like) on heel of foot)
Stage III: full thickness tissue loss with fat, slough may be present, drainage and infection may be present , purulent
discharge (thick milky), full had to toe
Stage IV: full thickness tissue with exposed bone, muscle, or tendon , escare (black), HEAL BY SCAR FORMATION !
Unstageable : depth is unknown, completely obscured by slough (yellow, tan , green) or escar (tan to black), can be a
III or a IV, suspected deep tissure injury, purple or marron, localized, intact skin, blood filled blister
Assess the type of tissue amount, appearance(color), viable/nonviable tissue, granulation tissue (red moist new blood
vessels healing) , slough must be removed by skilled tech or wound dressing
Protein is important for skin (wound healing)
albumin level 3.5 to 5 (less than 3.5 means lacking protein skin breakdown)
hydrogel/hydrocolloid dressing (moisture) provided for healing
low air therapy units decrease pressure
Q2 turns!
Healing:
