Integumentary Flashcards
Risk factors for impaired skin integrity
nutrition age mobility hydration sensory perception moisture vascular integrity disease
Reduce risk for impaired skin integrity
proper nutrition and hydration hygiene turning q2h proper lifting special mattress pillows protect bony prominence
Stage I pressure ulcer
intact, nonblistered skin
nonblanchable erythema
Stage II pressure ulcer
partial thickness wound
does not extend deeper than dermis
shallow, superficial with pink wound bed
Stage III pressure ulcer
full thickness wound
extends into SQ tissue but not deeper
undermining or tunneling may be present
Stage IV pressure ulcer
Exposure of muscle, bone, connective tissue
Unstageable pressure ulcer
full thickness wound
amount of necrotic tissue makes it impossible to assess depth and underlying structures
Dehiscence
partial or complete separation of tissue layers during healing process
Evisceration
Total separation of tissue layers allowing protrusion of visceral organs
factors affecting wound healing
age
nutrition
disease process
infection
nursing interventions to prevent dehiscence or evisceration
splinting or using binder while coughing, deep breathing, movement
What do you do if dehiscence or evisceration occurs?
cover wound with gauze moistened with normal saline and notify dr
Diet for wound healing
high protein, carbs, vitamins with moderate fat intake
30-35 kcal/kg/day
1.25–1.5 g protein/kg/day
What size needle/syringe do you need to get enough pressure to debride wound?
19g
30 mL syringe
Primary intention
ends are approximated
heals quickly
minimal scarring
ex: paper cut or surgical incision