Skin integrity, and wound care Flashcards
Stage one pressure injury, intact. What type of dressing would we use?
None or transparent dressing or hydrocolloid
How does a transparent dressing work?
Protects from sheer. Do not use transparent dressing in presence of excessive moisture.
Stage two pressure injury status is clean. What type of dressings do we use?
Composite film, hydrocolloid, hydrogel, covered with foam or gauze dressing.
What is the purpose of a composite film dressing?
Limits sheer
What is the purpose of the hydrocolloid
Change when seal of dressing breaks; maximum wire times seven days heals through re-epithelialization
Hydro gel covered with foam or gauze dressing provides what for the stage of wound
Provides moist environment for the stage two pressure injury
Pressure injury stage three clean status what type of dressing would we use?
Hydrochloride, hydrogen, covered with foam dressing, calcium, alginate, gauze, growth factors
Calcium alginate significance
Use when there is significant exudate cover with secondary dressing
Gauze dressing, purpose
Use with normal saline or other prescribed solution solutions. Bring out excessive solutions; unfold to make contact with wound. Cover with dry dressing tape in place.
Growth factors dressing
Use with gauze per manufacture instructions
What is the expected change for a stage three pressure injury
They expected change is that it will heal through granulation and re-epithelialization
Pressure in entry stage four clean status what dressings?
Hydrogen, covered with foam dressings, calcium, alginate, gauze
What is the expected change for the stage four pressure injury
Heals through granulation, scar, tissue development, and re-epithelialization
Pressure injury stage is unstable wound covered with SR what type of dressings?
Adherent, phone, gauze, plus ordered solution, enzymes, none
Gauze plus ordered solution for unstageable why?
Deliver solution in may soften the eschar
What are the expected changes for the unstable pressure injury?
Eschar lifts to edges as healing progresses or eschar loosens overtime
What does enzyme dressings do?
Breaks down ESCHAR, providing debridement
Why would there be no dressing over a unstable pressure injury?
If the ESCHAR is dry and intact and debridement is not part of the plan of care, no dressing is used, allowing ESCHAR to act as physiological cover
Hydrocolloid dressings support healing by
Automatically deeds, necrotic wounds
Hydrogel dressings are?
Gauze or sheet dressings impregnated with water or glycerin based amorphous gel
What does the Hydrogel do for the wound?
It hydrates the wound and absorbs small amount of exudate
Pressure injury sites and bony prominence most frequently underlining pressure injury
Chin, Tranter, knee, pretibial crest, and for posterior it is the occipital bone, the scapula, the elbow, the spine process, sacrum, ischium,Achilles tendon, heel, soul, ear, shoulder and more see page 1333 in textbook
When obtaining a wound culture from where should the specimen be taken?
The wound after it has first been cleaned with normal saline, so the skin flora is removed.
When a patient’s surgical incision are approximated, which type of healing does this signify?
Primary intention
