Tissue Integrity Flashcards
What are the 3 phases of wound healing?
- Inflammatory
- Granulation
- Maturation
How long does the inflammatory phase last?
3-5 days
How long is the granulation phase?
5-21 days
What occurs during the maturation phase?
scar formation and contraction occurs
What is a primary intention wound healing?
clean-cut wound
risk for infection is low
minimal scar formation
What is secondary intention wound healing?
pressure wound, burns
wound left open and filled with scar tissue
What is tertiary intention wound healing?
infected wound after sutures
wound was closed and is open again
What is shearing?
the force created when layers of tissue move on each other
(always occurs with friction)
What are some dietary interventions?
protein
vitamin A
vitamin C
iron
What acronym promotes reducing the risk of melanoma?
SMART
What does SMART stand for?
Spend time in the shade between 11-3pm
Make sure you never burn
Aim to cover up
Remember to take extra care with children
Then use SPF of 15 or higher
How long does SPF 15 protect skin for?
150min
Sunscreen use?
- apply 30min before exposure
- reapply every 2 hours
- not recommended for babies under 6 months old
What does the ABCDEs of melanoma detection stand for?
Asymmetry
Borders
Color
Diameter (larger than a pencil eraser 7mm)
Evolving
When providing irrigation of a wound what solution do you use?
normal saline
At what stages of pressure injuries do hospitals not receive reimbursement?
3 and 4
What scale is used to asses for risk factors for skin breakdown?
Braden scale
What is included in the Braden scale?
sensory perception
moisture
activity
mobility
nutrion
friction and shear
What score on the Braden scale indicates a higher risk?
the lower the score
What areas are more at risk for skin breakdown?
head
shoulder
sacrum
buttock
heel
When trying to alleviate pressure over boney prominences, do not elevate HOB more than…
10-20 degrees
Exceptions: COPD, CHF (elevate knees first)
What should be used in skin folds?
water insoluble creams
- don’t use powder
When should nutritional status be completed?
within 24 hours of admission
How much protein can a patient lose with an open, weeping pressure ulcer?
50g per day
What what level should hemoglobin be maintained to promote wound healing?
12g per 100mL
What is an example of autolytic debridement?
dressings
What is nevi?
a mole
What is pruiritis?
itching
