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NUR 104-Chpt 39

Integumentary System & Wound Care

What type of subjective data would you collect on the integumentary system? Medical & Surgical-surgery, reasons for scars, biopses, diabetes, skin disorders Allergies-foods, meds Meds-can cause photsensitivity, kill normal flora Health Patterns
What type of objective data would you collect on the integumentary system? Inspection-color, size (metric system), distrubition (grouped, singular), location, shape, tattos, needle marks, bruising, nailbeds, scalp, hair Palpation-temp, turgor, moisture, texture
If the skin is red, how would you assess to determine if there is any underlying trama? feel for temp, push down to see if skin blanches
Name 3 types of Neoplasms and their category. Nonmelanoma: 1. Basal Cell Carcinoma 2. Squamous Cell Carcinoma 3. Malignant Melanoma
Which neoplasm is the least deadly and most common? Basal Cell Carcinoma
Which neoplasm can occur due to exposure to sun and smoking, and isn't too common, but CAN cause death. Squamous Cell Carcinoma
Which neoplasm can be found in eyes, gut, bowel and is extremely serious and deadly? Malignant Melanoma
What tool can you use to keep a close eye on a suspicious lesion to help prevent neoplasms? A-asymmetry B-border C-color D-diameter (if >6mm, serious!!!) E-evolving (changing color, shape, etc)
How do you treat fungal lesions? keep area dry and away from moisture use topical antifungal ointment take oral antifungal meds
How do you treat viral lesions? antiviral tx
How do you treat bacterial lesions? antibiotics (oral, topical) heat vasodialtes, thus increasing leukocyte to area (to fight it off)
Give an example of fungal lesions Tinea capitis
Give an example of viral lesions plantar warts
Give 3 examples of bacterial lesions Staph infections, MRSA, impetigo,
How do you treat allergic conditions of integumentary? antihistamines, topical creams, epinephrin (epi pen-if severe)
What is a pressure ulcer? localized injury to skin and/or underlying tissue, usually over a bony prominence
What causes a pressure ulcer? Pressure or pressure & shear
Explain Stage I of pressure ulcers. damage in epidermis (redness-no break) will not blanch when applying pressure
Explain Stage II of pressure ulcers partial thickness loss dermis damaged (break in skin) shallow open ulcer no slough can be a blister with clear fluid
Explain Stage III of pressure ulcers full thickness loss subcutaneous tissue damage (no bone, tendon,muscle exposed) tunneling undermining possible slough
Explain Stage IV of pressure ulcers full thickness loss bone, muscle, tendon exposed slough/eschar can be present
Explain Unstageable stage of pressure ulcers full thickness loss base of ulcer covered with slough &/or eschar
What part of the body would you want to leave Eschar? Heels
Explain Suspected Deep Tissue Injury (DTI) in pressure ulcer stages. purple or maroon blood filled blister due to damage to underlying soft tissue or shear or pressure must heal on its own
In the wound healing process what happens to a partial thickness wound? epithelialization-epidermal cells reproduce and migrate across the surface of the wound
In the wound healing process what happens to a full thickness wound? granulation tissue develops (proliferation stage), as its produced it fills with CT
What would be subjective data for wound care? Medical History Current Meds Allergies
What would be objective data for wound care? dimensions & location tissue exudate (drainage) surrounding tissue pain level neurovascular
How would you assess a neurological or vascular injury? check capillary refill (for good perfusion) check pulse check temp of extremeties sensation in fingertips wiggle toes and fingers
What is a partial thickness wound? AKA Primary intention Sliced, clean incision, not extremely damaged Ex:slicing bread with a knife
What is a full thickness wound? AKA Secondary Intention Torn tissue, lots of damage Ex:tearing bread apart
What are the phases of wound healing with a partial thickness wound? 1. Hemostasis 2. Inflammatory Phase 3. Proliferative Phase
What are the phases of wound healing with a full thickness wound? 1. Hemostatis 2. Inflammatory Phase 3. Proliferative Phase 4. Maturation
What is Hemostatis? 1st phase of wound healing -stop the blood flow to that area
What is Inlammatory Phase? 2nd phase of wound healing -swelling, dialated blood vessels, leukocytes rush to site
What is Proliferative Phase? 3rd phase of wound healing -new skin cells grow
Approimately how long until the proliferative phase? It requires what to heal? -3 days -wet, moist surface
What is Maturation? 4th phase of wound healing (only full thickness) -wound matures, scar tissue forms appx: 3wks-2yrs
What does granualtion indicate? new tissue forming
Once the skin is damaged, about how much does it go back to the way it was before? 80%
What is a priority when checking a wound? Checking the pulse (for perfusion)
What type of fluid is bright red blood? Sanguineous
What type of fluid is pustular drainage (green, milky)? Purulent
What type of fluid is clear liquid? Serous
What type of fluid is a mix of clear fluid and pinkish, orange liquid? Seroussanguineous
What is debridement? removing slough
What is the purpose of dressing a patients wound? -protection -absorb drainage -keep wound bed moist -debridement
What is the purpse of transparent dressing? -keep it moist, but is breathable but doesn't allow baceria to get in -often used in IV sites
What is the purpose of Hydrogel dressing? dauze with hyrdogel in it cooling gel helps with pain
What is the purpose of Hydrocolloid dressing? -more cost effective -keeps moisture in -doesn't absorb exudate -can stay on up to 3 days
What is the purpose of Silver Dressing? antimicrobial factors good for infected wounds
What is the purpose of Foam dressing? good absorption of wounds with lots of drainage
What is the purpose of Calcium Alginate? good for wounds with lots of drainage good for packing helps debride the wound
What are some nursing diagnoses related to Integumenatry? 1. Impaired Skin Integrity 2. Impaired Tissue Integrity 3. Risk for impaired Skin Integrity
What is the difference in Impaired Skin Integrity and Impaired Tissue Integrity? -Skin Integrity: disruption of epidermis, destruction of layers (dermis) or invasion of body structures -Tissue Integrity-damaged or destroyed tissue must be present
What would be some nursing interventions for integumentary? 1 First aid for minor wounds 2 Pruritus relief (itching) 3 Prevent secondary infections 4 Tx of denuded/excoriated skin (torn off/looks red) 5 Dressing Changes 6 Wound support (staples sutures glue etc) 7 Drainage Management (closed or open) 8 Heat
List one way to decrease pruritus? wet dressings
What is dehiscence? accidental seperation of wound edges
What is evisceration? Protrusion of internal organs through an open wound
What is teriary intention? a delay in the closure of the wound to get bacteria out
The nurse knows that 1st day surgical site that has erythema is normal or abnormal? How about on day 5-6? -normal -abnormal
Gauze is cost effective and can be used to cover an incision site with minimal drainage. And is good for removing slough, in what type of wound should it NOT be used? In a wound with beefy red tissue
Created by: jessicaspring