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Turner Skin Integ.
Dr. Turner Skin integrity falsh cards .
| Question | Answer |
|---|---|
| The skin is made of what three layers? | The Epidermis, the dermal-epidermal junction, and the dermis. The dermis provides strength and support blood vessels and nerves. |
| What are pressure ulcers? | Known as decubitus unclers,pressure sores, bedsores, They are localized injury to the skin and underlying tissue. |
| What causes Pressure ulcers? | Immobility, friction & shearing, moisture, age, sweating, malnutrition. |
| Where do pressure ulcers occur? | Boney prominences. Elbows, hips, knee, ischium, scapula, the trochanter. |
| What is the pathway of vessels from heart- to heat? | from heart to aortia > arteries> arterioles> capillaries> veiniols> veins> heart |
| What is the diameter of a capillary? | about 8 micrometers |
| How much pressure will occlude capillary flow? | 15 - 32mmHg Blood flow occulded at 15-32mmHg can cause ischemia |
| What is ischemia? | reduced blood flow to an area, decreases oxygen supply to and area. |
| What is blanching? | The area turns white with pressure. |
| What is a stage 1 pressure ulcer | intact skin with nonblanchable redness. (reactive hyperemia) |
| What is a stage 2 pressure ulcer? | Partial thickness skin loss, involves the epidermis , dermis, or both such as a blister or crater. Has a red- pink area wound the wound bed without slough or other yellow sticky substances. |
| What is a stage 3 pressure ulcer? | Full thickness tissue loss with visible fat on the edges, deep area could be shallow-deep depending on the area. Some slough possible. |
| What is a stage 4 pressure ulcer? | Full thickness tissue loss with exposed bone, muscle, or tendon. Smell bad, possible undermining or tunneling. |
| What is an unstageable pressure ulcer? | When you can't see just how deep it is because it's covered by slough. |
| What are the stages of healing in a partial thickness wound? | Inflammatory phase, epithelial proliferation,and migration. |
| What are the stages of healing in a full thickness wound? | homeostasis, inflammatory, proliferation, and remodeling. (scar is stronger that tissue it replaces. |
| What is hemorrhage? | bleeding at the wound site. normally stopped within minutes by hemostasis |
| What is shock known as? | Hypoxemia |
| What are the physical signs of shock? | blood pressure decrease, Pulse increases- tachycardia, paleness in skin. Blood supply shunted to the extremities for core use. Respiratory increases, rapid heart rate, O2 low |
| Wound infection ranks where among HAI? | The second most common. UTI is the first most common. |
| What is a fistula? | communication between two organs or passage way that should not be communicating (trachesopogial fistula)- (rectum-vagina) (drainage coming from one area that should be coming from another.) |
| How do we prevent and predict pressure ulcers? | Braden Scale. |
| What areas does the Braden scale measure? | Sensory perception, moisture, activity, mobility, nutrition, friction & shear |
| What Items should you assess when checking for pressure ulcers? | Skin, presence of ulcers, mobility, nutrition and fluid status, pain, existing wounds, appearance, character, wound cultures. |
| What can we implement to protect skin intergrity? | Topical skin care- protect bony prominence, skin barriers for incontinence Positioning turn every 1-2 hours (90 minutes may be better) as needed •Support surfaces, Decrease the amount of pressure exerted over the bony prominences. 30 degree tilt |
| "Time wounds all heels" | The longer a person lies on back with heels against mattress more skin breakdown |
Created by:
dgreen158
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