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Turner Skin Integ.

Dr. Turner Skin integrity falsh cards .

QuestionAnswer
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