integumentary Flashcards
stage 1 pressure ulcer
reddeddned area that does not go away
stage 2 pressure ulcer
first 2 layers of skin, superficial in nature
stage 3 pressure ulcer
subcutaneous fat may be visible
stage 4 pressure ulcer
down to the bone and including the bone
unstageable pressure ulcer
is related to not visualizing the wound base bc of necrotic tissue
dressings from dry to wet
film - hyrdogel - hydrocollois - foams - calcium alginates, hydrofiber
types of selective debridement
sharp
enzymatic
autolytic
types of nonselective debridement
wet to dry
wound irrgation
hydrotherpay
superficial burn
epidermis only
dry, red skin, without blister
superficial partial thickness
epidermis and some dermis
weeping/intact blisters
blanches to pressure with quick capillary refill
extremely painful
shiny appearance
A superficial partial-thickness burn would be wet, with a shiny and weeping surface, and mottled red in color.
deep partial thickness
epidermis and dermis
mottled red and white wazy areas
blances to pressure with slow capillary refill
decreased pinprick sensation
broken blisters
marked edema
full thickness burn
epidermis, dermis, and some subcutaneous tissue
- dry, rigid, leathery eschar
- lack of pain, pressure, temp sensation
White color would characterize a full-thickness burn
A full-thickness burn would have fat exposed
subdermal burn
epidermis, dermis, subcutaneous tissue
- charred, dry, and exposed deep tissue
rule of 9s
with babies:
head is total of 17% (8.5 + 8.5) - ADULT 9
arms: 9 % - SAME ADULT
legs: 13% (6.5 + 6.5) - ADULT = 18
chest: 36% (18 + 18) - SAME AS ADULT
groin: 1% for both baby and adult
Compare hypertropic scar v keloid scar
hypertropic:
- scarring that remain within the original border
keloid:
- excessive scar tissues grows outside of the orignal margins of the wound
