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Skin & wound care

MCC fall10 block 1 kozier ch 36

QuestionAnswer
List the 5 factors that affect skin integrity... 1. genetics/heredity, 2. age, 3. chronic illness/treatment, 4. medications, 5. poor nutrition
The types of clients who are at risk for pressure ulcers are... those who are at an advanced age, immobile, have diminished sensations, excessive body heat, poor nutrition, incontinence, & decreased mental status
Pressure ulcers come in how many stages? 4 Stages
Describe a Stage 1 pressure ulcer: A nonblachable erythema signaling potential ulceration.
Describe a Stage 2 pressure ulcer: Partial-thickness skin loss involving epidermis and possibly dermis.
Describe a Stage 3 pressure ulcer: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue
Describe a Stage 4 pressure ulcer: Full-thickness skin loss with tissue necrosis or damage to muscle, bone or supporting structures
External causes of pressure ulcers Friction/shearing, poor lifting/transfering, incorrect positioning, hard support surfaces, & incorrect application of pressure-relieving devices.
Name four ways to prevent pressure ulcers. 1. Provide proper nutrition, 2. maintain skin hygiene, 3. avoid skin trauma, 4. provide supportive devices
Descibe Primary wound healing characteristics The tissue surface is closed, there is minimal or no tissue loss, and there is formulation of granulation and scarring.
Describe Secondary wound healing characteristics. There is extensive tissue loss, the edges can not be closed, the repair time is longer, the scarring is greater, and there is a higher susceptibility to infection
Describe Tertiary wound healing characteristics. The wound is initially left open, edema, infection, or exudate resolves and then the wound is closed.
Identify the three major types of exudate. Serous, Purulent, Sanguineous (hemorrhagic)
What are the characteristics of Serous exudate? Serous exudate is mostly serum, watery and clear of cells (like fluid in a blister)
What are the characteristics of Purulent exudate? Purulent exudate is thicker, has pus, odor and color (can be blue, green, or yellow)
What are the characteristics of Sanguineous exudate? Sanguineous exudate is hemorrhagic (bloody), has a lrge # of RBC's and indicative of severe capillary damage.
What are the complications associated with would healing? Hemorrhage, infections, dehiscence (partial or rupturing of a wound), and evisceration (protrusion of internal viscera through and incision).
List four factors that affect wound healing. 1. age, 2. nutrition, 3. lifestyle, 4. medications.
Identify assessment data for untreated wounds. Check location, extent of tissue damage, wound LxWxD, bleeding, foreign bodies, any associated injuries, and last tenus shot.
Identify assessment data for treated wounds. check appearance, size (LxWxD), drainage, presence of swelling, pain level, and status of drains/tubes.
Name the three phases of wound healing. 1. Inflammatory, 2. Proliferative, 3. Maturation
Describe the Inflammatory Phase of wound healing. Immediately after injury, lasts 3-6 days, two major process occur during this phase: hemostasis (cessation of bleeding), phagocytosis (pac-man cells move into engulf cellular debris)
Describe the Proliferative Phase of wound healing. Occurs post injury on day 3/4 to 21. Collagen synthesis begins (whiteish chunky protein in wound) and granulation (beefy red) tissue forms.
Describe the Maturation Phase of wound healing Occurs around day 21 until 1/2 years post injury. Collagen is structured/organized (not blotchy) and the wound is remodeled and contracted. Scarring is formed.
RYB color guide to wound care means: R (red) = Protect: Y (yellow) = Cleanse; B (black) = Debride.
Desribe ways to promote wound healing and prevent complications. Increase fluid intake, monitor zinc, protein, and vitamins, get dietary consult (supplements) monitor weight/lab values, prevent microorganisms, and transmission of pathogens.
List some types of wound dressings; Transparent film (protection), impregnated non-adherent (cover wounds w/o exudate), hydrocolloids (absorbs), clear absorbant acryllic (bacterial/shearing protection), hydrogel (liquiefy naecrotic) , polyurethane foam (absorb), alginate (ordor absorbing)
List the types of bandages Gauze, elasticized, and binders (girdles)
Gauze bandage is used for... Retain dressings on wounds, and bandage hands and feet
Elasticisized bandage is used for... To provide pressure to an area, and improve venous circulation in legs
Binders are used for... The support of large areas of the body. Ex: Girdle and triangular arm sling.
What are the indications for using a HEAT? Muscle spasm, inflammation, pain, contracture, joint stiffness
What are the effects of using HEAT? Vasodilation, increase capillary permeability, increase cellular metabolism, increase inflammation, produces sedative effect
What are the indications for using COLD? Muscle spasms, inflammation, pain, traumatic injury.
What are the effects of using COLD? Vasoconstriction, decrease in capillary permeability, decrease in cellular metabolism, slows bacterial growth, and decreases inflamation. Has a local anesthetic effect
Cold application ranges: Celcius very cold 15* for ice bags. Cold 15-18* for cold packs. Cool 18-27* for cold compress.
Heat application ranges: Celcius Tepid 27-37* for alcohol sponge bath, Warm 37-40* for warm bath/aquathermia pads, Hot 40-46* for hot soak/compress/irrigation, Very hot 46* above for hot water bags for adults
Viral skin infections Herpes Zoster and Herpes Simplex
Herpes zoster is an infection caused by varicella zoster virus "shingles"
Herpes simplex Type 1 is typically occurs in the mouth. Type 2 typically occurs on the genitals.
Tinea type infections are what type? bacterial or fungal? Fungal (Myotic) Infections
Tinea Pedis is athletes foot
Tinea Corporis is Ringworm of the body
Tinea Capitis is Ringworm of the scalp
Tinea Cruris Ringworm of the groin
Pediculosis is Infestation with lice
When you are infected with the itch mite Sarcoptes scabiei you have... Scabies
Chronic Venous Insufficiency (CVI) is when.. you have inadequate venous return (venous blood travels up to the heart from the LE) over a prolonged epriod of time.
An increases in venous pressure equals impaired arterial circulation
A decrease in O2 and nutrients means cellular death
What is happening when a patient exhibits hard, shiny skin? skin atrophies and the subq fat deposits become necrotic
When RBC's begin to breakdown skin starts to look ... brown and ulcers start to develop
PVD stands for Peripheral Vascular Disease
Signs of PVD Brown/purple discoloration around ankles. Persons prone for DVT (Deep Vein Thrombosis)
Signs of Venous Ulcers with CVI Located over medial or interior ankle, superficial (pink color), skin has a brown discoloration that turns cyanotic when on it, normal skin temp, usually edematous, mild/aching pain, normal pulses
Signs of Arterial Ulcers with CVI Located over toes, feet, shin, ulcer is deep and pale, skin remains pale colored when elevated & turns red when walking, skin is cool to touch, none/little edema, severe/constant pain, may get infected (gangrene), pulses are decreased/absent
Patient Education for CVI Elevate legs, Walk/avoid long periods of sitting/standing, No leg cross, no restrictive clothes, TED hose when prescribed, keep skin clean/soft/dry, prevent injury & inspect daily
Medical care for Stasis Ulcers includes... NS wet/moist gauze dressings, possible diluted topical antibiotic, Unna boot (Semirigid) padded bony parts, changed 1/2weeks, hyperbaric chamber, surgery for large non healing areas
Common types of venous insufficiency include... Deep Vein Thrombosis, Vericose Veins, Stasis Dermatitis and Ulcer
List the six types of wounds 1. Incision, 2. Contusion, 3. Abrasion, 4. Puncture, 5. Laceration, 6. Penetrating wound
An incision is an open wound; deep or shallow, caused by a sharp instument, knife/scalpel
A contusion is a closed wound, skin appears bruised (ecchymotic) due to damaged blood vessels, caused by a blow from blunt instrument
An abrasion is an open wound involving the skin caused by a surface scrape (scrapped knee) unintentional (dermal abrasion to remove pockmarks on face (intentional)
A puncture is and open wound, penetration of the skin and underlying tissue caused by a sharp instrument
A laceration is open wound with jagged edges due to tissue being torn apart usually from accidents (machinery)
A penetrating wound is an open wound that usually penetrates the skin and underlying tissue and is usually unintentional (a shooting)
What is ischemia? a deficiency in the blood supply to the tissue.
What is maceration? issue softened by prolonged wetting or soaking. Incontinence can cause this.
What is excoriation? the loss of the superficial layers of the skin AKA: DENUDED
what is hemostasis? the cessation of bleeding. Hemostasis is when bleeding is halted to an injured blood vessel (vasoconstiction) so that cellular repair can begin.
What is a Keloid? A type of raised scar formed from too much fibrin/collagen being deposited into the wound. It usually goes beyond the original wound borders.
What is a hemotoma? A bruise. Collection of blood underneath the skin.
The partial or total rupturing of a sutured wound is called... dehiscence.
The protrusion of the internal viscera through an incision is called.. evisceration. When the inside of a wound is popping out.
What is debridement? When you remove dead tissue/necrotic nonviable tissue from a wound.
NANDA Diagnosis: "Risk for Impaired Skin integrity" relates to At risk for skin being adversely infected
NANDA Diagsosis: "Impaired Skin Integrity" relates to Altered epidermis and/or dermis. Applies to pressure ulcers and to wounds extending through the epidermis but not through the dermis.
NANDA Diagnosis: "Impaired Tissue Integrity" relates to Damage to mucous membranes, corneal, integumentary, or subcutaneous tissue. Applies to pressure ulcers and wounds extending to subq tissue, muscle, or bone
Teaching skin integrity. To maintain intact skin educate about relatioship between adequate nutrition and healthy skin (protein, vitamins b/c, iron, hydration. Appropriate positions to relieve pressure, turn schedule, use of skin protection or applications, reporting of red areas, identify potential sources of trauma
Teaching skin integrity. To promote wound healing educate about Nutrition (protein, vit b/c, iron, hydration. Instruct in wound assessment/documenttion, asepsis hand hygiene, s/s of wound infection to report, prevention, demonstrate wound care techniques, pain control
Created by: lucky duck
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