Unit six skin integrity Flashcards
(18 cards)
What are the types of wounds?
Abrasion, puncture, laceration, surgical incision
Each type of wound has distinct characteristics and healing processes.
What is skin breakdown?
A condition where the skin loses integrity, often leading to pressure injuries
Causes include prolonged pressure, friction, and moisture.
What are the most common locations for skin breakdown?
Sacrum, heels, elbows, and other bony prominences
These areas are more susceptible due to pressure and limited blood flow.
What are the stages of pressure injuries?
Stage I, Stage II, Stage III, Stage IV
Each stage reflects the severity of skin and tissue damage.
How are risk factors for skin breakdown evaluated?
By assessing mobility, nutrition, moisture, and sensory perception
This data helps in identifying patients at risk.
What nursing measures help prevent skin breakdown?
Regular repositioning, skin care, nutrition management, and use of pressure-relieving devices
These actions are crucial in maintaining skin integrity.
What procedures and equipment are used for pressure injuries?
Debridement, dressing changes, and use of specialized wound care products
Equipment may include wound vacuums and hydrocolloid dressings.
What are the three types of wound healing?
First-intention, second-intention, third-intention
Each type describes different healing processes based on wound characteristics.
What are common complications of wound healing?
Hemorrhage, infection, dehiscence, evisceration
These complications can severely affect recovery.
What are three purposes of wound dressings?
Protect the wound, absorb exudate, and promote healing
Dressings support the healing environment and prevent infection.
How do you change a dry, sterile dressing?
Clean the area, remove the old dressing, apply a new sterile dressing
Follow aseptic techniques to prevent infection.
What are common types of wound drainage systems?
Penrose drain, closed drainage system, vacuum-assisted closure machine
These systems help manage wound exudate and promote healing.
How are sutures and staples removed?
By using a sterile suture removal kit, cut the suture and pull it out gently
Staples are removed with a staple remover tool.
What are the classifications of burns?
First-degree, second-degree, third-degree, fourth-degree
Each classification reflects the depth and severity of the burn.
What is the immediate first aid for minor burns?
Cool the burn under running water, cover with a sterile dressing
Avoid using ice directly on the burn.
What components are included in wound assessment?
Inspection/description, drainage, other characteristics of wounds
Thorough assessment is crucial for effective wound management.
What are the principles of wound irrigation?
Use sterile saline, apply gentle pressure, and ensure thorough cleaning
Proper irrigation helps to remove debris and bacteria.
What types of dressings are used in wound care?
Dry, sterile dressing, gauze, nonadherent dressing, ABD pad, alginates, hydrocolloid, transparent dressing, foam dressing
Each dressing type serves specific purposes based on the wound characteristics.
