Skin Integrity Flashcards
avulsion
An avulsion involves stripping away of large parts of tissue leaving cartilage and bone exposed
puncture
A puncture involves an opening of skin caused by a narrow, sharp, pointed object
laceration
A laceration involves separation of skin and tissue with torn, irregular edges
contusion
A contusion is an injury to soft tissue.
what is considered a skin appendage
Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. NOT CT
The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?
Impaired tissue integrity
desiccation
the process of drying up. Cells dehydrate and die in the environment this delays healing
macceration
over hydration result from excessive exposure to mostuire
Dehiscence
is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed
Evisceration
is the most serious complication of dehiscence. The wound separates completely with protrusion of viscera through the incisional area.
A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?
Penrose
Purpose and example of Jackson-Prattt use
Purpose: decreases dead space by collecting drainage
Example: after breast removal and abdominal surgery
Purpose and example of Hemovac
Purpose: decreases dead space by collecting drainage
Example: after abdominal, orthopedic surgery
Purpose and example of Penrose
Purpose: provide sinus tract
Example: After incision and drainage of abscess, in abdominal surgery
The wound description reveals a beefy red wound bed that bleeds easily. What phase is that?
This is the proliferation stage and describes granulation tissue
Hemostasis is
Hemostasis is the initial phase that involves activation of platelets.
during homeostasis the same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured forming excudate
The inflammatory phase involves
white blood cells and macrophages entering the wound to remove debris from the wound.
The maturation phase involves
collagen remodeling and scar formation.
in wounds that heal by first intention, epidermal cells seal the wound within
24 to 48 hours
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?
reduce time interval between dressing changes
When performing a dressing change, the home care nurse notes that base of the client’s leg wound is red and bleeds easily. Which of the following is the appropriate action by the nurse?
document the findings
functional
unable to make it to bathroom
urge
urge to urinate may be difficult to control, leading to involuntary loss of urine
Over active bladd
Stress
over distention between voiding (holding urine)
weak Pelvic muscles and structural supports, dribbling of urine during laugh/coughing/sneezing for mothers
