Skin Integrity Flashcards
Functions of skin
UV protection
Temp regulation
Prevent loss of moisture
Produce Vitamin D
Promote Absorption
Local Factors affecting Wound Healing
Pressure
Drying up
Maceration
Edema
Repeated Trauma
Infection
Excessive Bleeding
Necrosis
Biofilm
Systemic Factors affecting wound health
Age
Circulation
Oxygenation
Anemia
Smoking
Nutrition
Medications
Immunosuppressed
Promoting Wound Healing
Prevent Infection
Promote Blood Supply
Wound needs to be free of drainage, dead tissue, fragments
Proper nutrition
Complication of wounds
Infection
Hemorrhage
Dehiscence/Eviseration
Fistula
Wound Assessment
Every 8 Hrs
Wound assesment
-apperance
-drainage
-sutures/staples
-odor
Pain Assessment
-what causes the pain
Psychosocial Aspect of Wounds
Pain
Anxiety
ADL’s
Body Image
Causes of Pressure Injury
Caused by pressure
Pressure Injury - Whos at risk
Immobile
Age
Nutrition/Hydration
Pressure Injury - Stages
Stage 1- non blanchable
Stage 2 - Broken skin
Stage 3 - some tunneling
Stage 4 - Lots of tunneling
Pressure Injury - Assessment
pt Hx
Apperance of skin
recent skin changes
activity/mobility
nutrition
pain
elimination
skin assessment
Pressure Injury - Nursing Intervention (at risk)
Assess often
braden scale
relieve pressure
reposition
pad bony prominance
keep pt less than 30 degrees
manage the pressure
Pressure Injury - Nursing Interventions (with wound)
Prevent infection
prevent further injury
physical and emotinal health
consult wound specialist
