Exam 2 Flashcards
Preventing alterations in skin integrity? (IINHPA)
Ice is not hot, poop ass
identification inspection nutrition hydration protection assessment
Risk factors for skin integrity are:
IM DD AR M
Im DD, alright mate?
impaired circulation medication dehydration decreased sensation age reduced mobility malnourished
alteration in skin integrity is a ___
wound
how to classify wounds?
CSCS D
classify scrapes, classify scrapes, duh
cause of wound status of skin integrity cleanliness of wound severity of tissue injury descriptive qualities
how to assess the wound?
WWW HTTOP
www. hot topic
what type of dressing what the periwound looks like what the wound bed looks like how much drainage on dressing type/amount of drainage tunneling/undermining pain
types of drainage
SSSP
(sss, pus) (sounds like its leaking, get it from a wound?
serous
serosanguineous
sanguineous
purulent
where is the top of the wound?
towards the head
what unit of measure is used to measure a wound?
centimeters
longest part is ___ to___ and widest part is ____ to the length
top to bottom
perpendicular
steps to first aid of a wound:
stop the bleeding
clean the wound
protect the wound w bandage
function of dressings
absorbs drainage
dressings need frequent ___ and ___
changing and monitoring
dressings must always have a
date, time and initial
pressure ulcers are over ___
bony prominence
pressure ulcers are ____ in health facilities
prevalent
pressure ulcers can cause:
extended stays, sepsis, mortality, cost increase
risk factors for pressure ulcers : AMFS (AMF’s can make you pass out and be immobile)
alteration in LOC
moisture
friction
shearing
Braden scale assesses risk in six categories: MF MANS
moisture friction/shear mobility activity nutrition sensory perception
what are the stages of pressure ulcers
unstageable stage 1 stage 2 stage 3 stage 4
what is an unstageable pressure ulcer
cannot see wound base
full thickness loss
completely obscured by slough or eschar (necrotic tissue)
characteristics of stage 1 pressure ulcer
skin is intact
does not blanch
(goal to prevent breakdown)
characteristic of stage 2 pressure ulcer
shallow, open ulcer
can be a blister filled w serosanguineous fluid
partial thickness loss of epidermis
red pink wound bed
characteristic of stage 3 pressure ulcer
full thickness loss may see subcutaneous fat sloughing could be present eschar could be present (scab) possible undermining or tunneling
stage 4 pressure ulcer characteristics
full thickness loss
exposed bone tendon or muscle
possible slough/eschar
often undermining and tunneling