Integumentary Flashcards

1
Q

Risk factors for impaired skin integrity

A
nutrition
age
mobility
hydration
sensory perception
moisture
vascular integrity
disease
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2
Q

Reduce risk for impaired skin integrity

A
proper nutrition and hydration
hygiene
turning q2h
proper lifting
special mattress
pillows
protect bony prominence
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3
Q

Stage I pressure ulcer

A

intact, nonblistered skin

nonblanchable erythema

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4
Q

Stage II pressure ulcer

A

partial thickness wound
does not extend deeper than dermis
shallow, superficial with pink wound bed

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5
Q

Stage III pressure ulcer

A

full thickness wound
extends into SQ tissue but not deeper
undermining or tunneling may be present

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6
Q

Stage IV pressure ulcer

A

Exposure of muscle, bone, connective tissue

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7
Q

Unstageable pressure ulcer

A

full thickness wound

amount of necrotic tissue makes it impossible to assess depth and underlying structures

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8
Q

Dehiscence

A

partial or complete separation of tissue layers during healing process

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9
Q

Evisceration

A

Total separation of tissue layers allowing protrusion of visceral organs

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10
Q

factors affecting wound healing

A

age
nutrition
disease process
infection

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11
Q

nursing interventions to prevent dehiscence or evisceration

A

splinting or using binder while coughing, deep breathing, movement

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12
Q

What do you do if dehiscence or evisceration occurs?

A

cover wound with gauze moistened with normal saline and notify dr

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13
Q

Diet for wound healing

A

high protein, carbs, vitamins with moderate fat intake
30-35 kcal/kg/day
1.25–1.5 g protein/kg/day

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14
Q

What size needle/syringe do you need to get enough pressure to debride wound?

A

19g

30 mL syringe

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15
Q

Primary intention

A

ends are approximated
heals quickly
minimal scarring
ex: paper cut or surgical incision

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16
Q

Primary intention healing phases

A

Initial: approximated edges, clot forms, plt release GF
Granulation: migration of fibroblast, secretion of collagen, wound is fragile; wound is pink and vascular
Maturation: remodeling of collagen and strengthening of scar

17
Q

Secondary intention

A

Heal upward from bottom and inward from sides
cannot be approximated
much larger scar d/t more granulation tissue

18
Q

Tertiary intention

A

occurs when contaminated wound is left open and closed after control of infection
results in larger and deeper scar

19
Q

3 phases of wound healing

A

Inflammatory
Proliferative
Maturation

20
Q

What happens during inflammatory phase?

A

bleeding, coagulation
release of GF and cytokines
increase of pain, redness, warmth, swelling
Macrophages and neutrophils at site

21
Q

What happens during the proliferative phase?

A
angiogenesis
fibroblasts produce GF, synthesize collagen
fills bed with granulation tissue
resurface wound with skin
bleeds easily
bumpy appearance
22
Q

What happens during the maturation phase?

A

remodeling phase

scar tissue forms and strengthens

23
Q

Documentation of a wound

A
color of wound bed and periwound
COCA of drainage
type of tissue in wound (granulation, eschar, slough, SQ)
s/sx infection
width, length, depth, undermining depth
24
Q

Film dressing

A

used as a secondary dressing for autolytic debridement
adheres to the damaged skin
barrier to fluid and bacteria
allows wound to breathe; O2 can pass through
promotes moist environment

25
What dressing would you use if wound has excessive exudate?
transparent film or hydrocolloid
26
What type of dressing would you use for a clean stage I pressure ulcer?
transparent film to protect from shear/friction | hydrocolloid
27
What type of dressing would you use for a clean stage II pressure ulcer?
composite film hydrocolloid hyrdrogel
28
What type of dressing would you use for a clean stage III pressure ulcer?
hydrocolloid hydrogel covered with foam dressing calcium alginate gauze with normal saline
29
What type of dressing would you use for a clean stage IV pressure ulcer?
hydrogel covered with foam dressing calcium alginate gauze with normal saline
30
What type of dressing would you use for an unstageable pressure ulcer covered in eschar?
adherent film (softens eschar) gauze with ordered solution enzymes