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NUR 152 Final Exam > Integumentary > Flashcards

Flashcards in Integumentary Deck (30)
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1

Risk factors for impaired skin integrity

nutrition
age
mobility
hydration
sensory perception
moisture
vascular integrity
disease

2

Reduce risk for impaired skin integrity

proper nutrition and hydration
hygiene
turning q2h
proper lifting
special mattress
pillows
protect bony prominence

3

Stage I pressure ulcer

intact, nonblistered skin
nonblanchable erythema

4

Stage II pressure ulcer

partial thickness wound
does not extend deeper than dermis
shallow, superficial with pink wound bed

5

Stage III pressure ulcer

full thickness wound
extends into SQ tissue but not deeper
undermining or tunneling may be present

6

Stage IV pressure ulcer

Exposure of muscle, bone, connective tissue

7

Unstageable pressure ulcer

full thickness wound
amount of necrotic tissue makes it impossible to assess depth and underlying structures

8

Dehiscence

partial or complete separation of tissue layers during healing process

9

Evisceration

Total separation of tissue layers allowing protrusion of visceral organs

10

factors affecting wound healing

age
nutrition
disease process
infection

11

nursing interventions to prevent dehiscence or evisceration

splinting or using binder while coughing, deep breathing, movement

12

What do you do if dehiscence or evisceration occurs?

cover wound with gauze moistened with normal saline and notify dr

13

Diet for wound healing

high protein, carbs, vitamins with moderate fat intake
30-35 kcal/kg/day
1.25--1.5 g protein/kg/day

14

What size needle/syringe do you need to get enough pressure to debride wound?

19g
30 mL syringe

15

Primary intention

ends are approximated
heals quickly
minimal scarring
ex: paper cut or surgical incision

16

Primary intention healing phases

Initial: approximated edges, clot forms, plt release GF
Granulation: migration of fibroblast, secretion of collagen, wound is fragile; wound is pink and vascular
Maturation: remodeling of collagen and strengthening of scar

17

Secondary intention

Heal upward from bottom and inward from sides
cannot be approximated
much larger scar d/t more granulation tissue

18

Tertiary intention

occurs when contaminated wound is left open and closed after control of infection
results in larger and deeper scar

19

3 phases of wound healing

Inflammatory
Proliferative
Maturation

20

What happens during inflammatory phase?

bleeding, coagulation
release of GF and cytokines
increase of pain, redness, warmth, swelling
Macrophages and neutrophils at site

21

What happens during the proliferative phase?

angiogenesis
fibroblasts produce GF, synthesize collagen
fills bed with granulation tissue
resurface wound with skin
bleeds easily
bumpy appearance

22

What happens during the maturation phase?

remodeling phase
scar tissue forms and strengthens

23

Documentation of a wound

color of wound bed and periwound
COCA of drainage
type of tissue in wound (granulation, eschar, slough, SQ)
s/sx infection
width, length, depth, undermining depth

24

Film dressing

used as a secondary dressing for autolytic debridement
adheres to the damaged skin
barrier to fluid and bacteria
allows wound to breathe; O2 can pass through
promotes moist environment

25

What dressing would you use if wound has excessive exudate?

transparent film or hydrocolloid

26

What type of dressing would you use for a clean stage I pressure ulcer?

transparent film to protect from shear/friction
hydrocolloid

27

What type of dressing would you use for a clean stage II pressure ulcer?

composite film
hydrocolloid
hyrdrogel

28

What type of dressing would you use for a clean stage III pressure ulcer?

hydrocolloid
hydrogel covered with foam dressing
calcium alginate
gauze with normal saline

29

What type of dressing would you use for a clean stage IV pressure ulcer?

hydrogel covered with foam dressing
calcium alginate
gauze with normal saline

30

What type of dressing would you use for an unstageable pressure ulcer covered in eschar?

adherent film (softens eschar)
gauze with ordered solution
enzymes