Integumentary Flashcards
Describe a macerated wound
White, friable, overhydrated, sometimes wrinkled
Type of dressing for very mild exudate
Transparent film
Type of dressing for minimal exudate
Hydrogel dressing or hydrocolloid
Type of dressing for moderate exudate
Foams
Type of dressing for heavy exudate
Calcium alginates, hydrofiber
Where is venous insufficiency usually seen in the LE
Proximal to the medial malleolus
Signs of venous insufficiency
Irregular, shallow appearance. Flaking, brownish discoloration (Hemosiderin staining). Mild-moderate pan. Elevation decreases pain
Signs of arterial insufficiency
Smooth edges, well defined. Thin and shiny, hair loss, yellow nails. Severe pain. Elevation increases pain
Where is arterial insufficiency usually seen in the LE
Lower 1/3 of leg, toe, lateral malleolus
Define stage 1 pressure ulcer
Reddened area that does not go away
Define stage 2 pressure ulcer
First 2 layers of skin, superficial
Define stage 3 pressure ulcer
Subcutaneous fat may be visible
Define stage 4 pressure ulcer
Down to the bone and including the bone
Define an unstageable pressure ulcer
Unable to visualize the wound base 2/2 necrotic tissue
T/F: herpes zoster has initial symptoms of pain and paresthesia localized to the affected dermatome
True
What is selective debridement
Removal of only non viable tissues from a wound
Options for selective debridement
Sharp, enzymatic, autolytic debridements
What is nonselective debridement
Removal of both nonviable and viable tissues from a wound
Options for nonselective debridement
Wet to dry dressings, wound irrigation and hydrotherapy
Clinical presentation for superficial burn
Dry, red skin, without open areas
Clinical presentation for superficial partial thickness burn
Intact, weeping blisters. Blanches to pressure w/ quick refill. Extremely painful
clinical presentation for deep partial thickness burn
Mottled red and white areas. Slow capillary refill. Decreased pinprick sensation
Clinical presentation of Full thickness burn
Dry, rigid, leathery. Lack of pain, pressure, temperature sensation
Percentage of arm for rule of 9s
4.5% per side per arm
Rule of 9s % for head
4.5% side
Rule of 9s for trunk
18% per side
Rule of 9s for legs
9% per side per leg
Rule of 9s for children: arm
4.5% per side per arm
Rule of 9s for children: head
8.5% per side
Rule of 9s for children: trunk
18% per side
Rule of 9s for children: legs
6.5% per side per leg
