Exam 3 part 2 Flashcards
what is the order of the skin from top to inside?
epidermis and dermis
what does skin do?
protects from infection
locks in moisture
protects from uv
vitamin d production
absorbs medication
how does skin change with age?
as you get older you
decrease in collagen production
decresed circulation
dehydration
slower cell replication
what factors affect skin integrity
occupation….healt status…diabetes…circulation issues…decreased oil production….immuno comprimised
what is a wound?
any break in the skin
what promotes faster wound healing?
nutrition…hand hygeine…blood supply
what are some local factors that can affect healing?
location….desacation….masceration…repeated trauma…edema..infection…bleeding..necrosis…eschar
what is desecation?
drying up of skin
what is masceration?
overhydration
what are some systemic factors that affect healing?
circulation problems…smoking….nutrition….meds….anemic… radiation…chemo meds…prolonged antibiotics…
how long does it take for infection to set in a wound?
2-7 days
what are signs and symptoms of infection?
increased temp….increased WBC…increased drainage…increased pain
what is hemorrhaging wound mean?
can be caused by stich opening up or infection
what does dehissence mean?
wound has opened up and muscle tissues is visiable
what does visceration mean?
muscle and oragns are visible
what should you do when dehiscence and evisceration occur?
put on sterile saline and call provider?
which one calls for immediate surgery dehiscence and evisceration?
evisceration
what are you looking for in wound assessment?
apperance….size…depth…drain…sutures, staples, glue..drainage color/smell
what is serous fluid?
clear fluid
what is sangionus fluid?
bloody fluid
what is serosanguinous fluid?
mix of blood and clear
what is purulent fluid?
infection….green
what does malodorous mean?
bad smell
what is a pressure injury?
bed sore caused by pressure….pressure leads to less ciruclation
what is friction?
the force of rubbing two surfaces against one another.
what is shearing?
pressure from and object
who is at risk for pressure injury/
immobile…bed rest…poor nutrition…overly hydrated….dehydrated…altered LOC…coma
what are the characteristics of a stage 1 pressure injury?
localized redness…..non blanch-able skin
what are the characteristics of a stage 2 pressure injury?
partial skin broken…blisters
what does non blanchable mean?
if pressed wont turn white when pressed
what are the characteristics of a stage 3 pressure injury?
broken skin…could have tunneling…
what are the characteristics of a stage 4?
bone and tendon showing….tunnnleing
what is the braden scale?
assesses fall risk in patients
what is the braden scale ranges
Risk 18 and belwo
No Risk: Total Score 19-23.
what braden scale number calls for intervention?
18 and below
