skin integrity Flashcards
What are the classification of pressure ulcers
stage1- damage to the epidermis- erythema
stage2- damage into the dermis- blisters/shallow craters
stage3- damage and necrosis through the subCut
Stage4- necrosis into the muscle, bone, or supporting structures
What is flat bed position used for
maintaining spinal alignment
assissting the client to move
What is fowlers used for
eating
reading
drinking
promoting lung expansion
What is semi-fowlers for
relief from lying position
lung expansion
What is fowlers degree
45-60 degrees
What is semifowlers
15-45
usually 30
What is Trendelenburg used for
promote venous return
provide postural drainage of basal lung lobes
What is reverse trendeleburg used for
promoting stomach emptying and preventing esophageal reflux in patients with hiatal hernia
What are the risk factors for skin integrity
friction and shearing immobility inadequate nutrition incontinence decreased mental status decreased sensation excessive body heat advanced age chronic conditions
What is a tool that can be used to assess the risk for pressure sores
the braden scale
What are the types of wound healing
primary and secondary intention
What is primary intention
the wound edges are approximated and there is minimal loss
What is secondary intention
extensive tissue loss and the edge arent or should not be apporximated
What are the stages of wound healing
inflammatory phase
proliferative phase
maturation phase
What are some complications of wound healing
hemorrhage
infection
dehiscence
