NPTE: Integumentary (scorebuilder 2008)
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| show | serous
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| show | sanguineous
• appears to be red due to presence of blood, or may be brown if allowed to dehydrate
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| Exudate classification: presents as light red or pink with a thin, watery consistency | show 🗑
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| Exudate classification: presents as opaque, yellow or tan color with thin, watery consistency | show 🗑
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| Exudate classification: presents as yellow or green with a thick viscous consistency | show 🗑
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| pressure ulcer staging • Stage I | show 🗑
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| pressure ulcer staging • Stage II | show 🗑
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| show | full-thickness skin loss that involves damage or necrosis of subcutaneous tissues. May extend to but not through underlying fascia.
• presents as a deep crater with or without undermining adjacent tissue.
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| pressure ulcer staging • Stage IV | show 🗑
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| show | no open lesion but may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity.
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| Wagner Grade 1 | show 🗑
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| Wagner Grade 2 | show 🗑
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| Wagner Grade 3 | show 🗑
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| show | gangrene of digit
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| show | gangrene of foot requiring disarticulation
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| Superficial burn | show 🗑
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| show | involves epidermis and upper portion of the dermis. may be extremely painful and exhibit blisters. minimal to no scarring.
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| show | involves complete destruction of the epidermis and majority of dermis. may appear discolored with broken blisters and edema. damages to nerve endings may result in only moderate pain. hypertrophic scars and keloids.
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| Full thickness burn | show 🗑
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| Subdermal burn | show 🗑
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| Definition: zone of coagulation | show 🗑
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| Definition: zone of stasis | show 🗑
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| show | the area surrounding the zone of stasis that presents with inflammation, but will fully recover without any intervention or permanent damage.
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| show | 9%
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| show | 18%
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| Rule of nines: • Posterior trunk | show 🗑
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| show | 9%
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| Rule of nines: • Bilateral posterior arm, forearm, hand | show 🗑
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| Rule of nines: • Genital region | show 🗑
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| Rule of nines: • Bilateral anterior LE | show 🗑
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| show | 18%
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| show | Child under 1 has 9% taken from the LEs and added to head region. Each year of life, 1% is added back to the LEs.
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| Topical agents used in burn care: • Can be used with or without dressing | show 🗑
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| Topical agents used in burn care: • Is painless | show 🗑
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| Topical agents used in burn care: • can be applied to wound directly | show 🗑
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| Topical agents used in burn care: • broad-spectrum | show 🗑
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| show | • silver nitrate
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| Topical agents used in burn care: • effective against yeast | show 🗑
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| show | • povidone-iodine
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| Topical agents used in burn care: • easily removed with water | show 🗑
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| Topical agents used in burn care: • penetrates burn eschar | show 🗑
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| show | • mafenide acetate
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| Topical agents used in burn care: • may be covered or left open to air | show 🗑
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| Topical agents used in burn care: • bacteriocidal | show 🗑
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| Topical agents used in burn care: • does not penetrate into eschar | show 🗑
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| show | • silver nitrate
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| show | • silver nitrate
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| show | • silver nitrate
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| show | • povidone-iodine
• nitrofurazone
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| show | • povidone-iodine
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| show | • povidone-iodine
• mafenide acetate
• nitrofurazone
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| show | • mafenide acetate
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| show | • mafenide acetate
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| Topical agents used in burn care: • may inhibit epithelialization | show 🗑
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| show | • gentamicin
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| Topical agents used in burn care: • ototoxic | show 🗑
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| Topical agents used in burn care: • nephrotoxic | show 🗑
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| Topical agents used in burn care: • may lead to overgrowth of fungus and pseudomonas | show 🗑
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| show | temporary skin graft taken from another human, usually cadaver
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| definition: autograft | show 🗑
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| definition: heterograft | show 🗑
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| definition: mesh graft | show 🗑
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| definition: sheet graft | show 🗑
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| definition: split-thickness skin graft | show 🗑
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| show | a skin graft that contains the dermis and the epidermis
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| burn location: anticipated deformity: • anterior neck | show 🗑
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| burn location: splinting type: • anterior neck | show 🗑
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| burn location: splinting type: • anterior chest and axilla | show 🗑
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| burn location: anticipated deformity: • anterior chest and axilla | show 🗑
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| show | flexion and pronation
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| show | gutter splint, conforming splint, three-point splint, air splint
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| burn location: anticipated deformity: • hand | show 🗑
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| show | wrist splint, thumb spica splint, palmar or dorsal extension splint
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| show | flexion and adduction
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| show | anterior hip spica, abduction splint
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| burn location: anticipated deformity: • knee | show 🗑
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| burn location: splinting type: • knee | show 🗑
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| burn location: anticipated deformity: • ankle | show 🗑
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| show | posterior foot drop splint, posterior ankle conforming splint, anterior ankle conforming splint
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| selective or non-selective debridement? • sharp | show 🗑
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| selective or non-selective debridement? • enzymatic | show 🗑
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| selective or non-selective debridement? • autolytic | show 🗑
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| show | non-selective
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| show | non-selective
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| show | non-selective
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| show | arterial
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| show | arterial
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| arterial or venous insufficiency ulcer? • location: dorsal foot | show 🗑
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| arterial or venous insufficiency ulcer? • location: lateral malleolus | show 🗑
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| arterial or venous insufficiency ulcer? • location: proximal to medial malleoulus | show 🗑
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| arterial or venous insufficiency ulcer? • appearance: smooth edges, well defined | show 🗑
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| arterial or venous insufficiency ulcer? • appearance: lack granulation tissue | show 🗑
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| show | arterial
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| show | venous insufficiency
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| show | venous insufficiency
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| show | arterial
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| arterial or venous insufficiency ulcer? • pain mild to moderate | show 🗑
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| show | arterial
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| arterial or venous insufficiency ulcer? • pedal pulse: normal | show 🗑
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| show | arterial
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| show | venous insufficiency
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| show | arterial
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| show | venous insufficiency
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| arterial or venous insufficiency ulcer? • tissue changes: thin and shiny | show 🗑
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| show | arterial
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| arterial or venous insufficiency ulcer? • tissue changes: yellow nails | show 🗑
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| arterial or venous insufficiency ulcer? • tissue changes: flaking | show 🗑
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| show | venous insufficiency
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| show | venous insufficiency
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| arterial or venous insufficiency ulcer? • leg elevation decreases pain | show 🗑
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| show | arterial
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| Dressing: used for partial and full-thickness wounds | show 🗑
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| Dressing: used for granular or necrotic wounds | show 🗑
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| Dressing: provides a moist environment for wound healing | show 🗑
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| show | • Hydrocolloids
• Hydrogels
• Foam Dressings
• Transparent Films
• Alginates
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| Dressing: Offers protection from microbial contamination | show 🗑
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| show | • Hydrocolloids
• Foam Dressing
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| show | • Hydrocolloids
• Adhesive version of Foam Dressing
• Gauze
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| Dressing: Provides a waterproof surface | show 🗑
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| Dressing: May traumatize surrounding intact skin upon removal | show 🗑
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| show | • Hydrocolloids
• Foam Dressings
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| Dressing: Cannot be used on infected wounds | show 🗑
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| Dressing: Used for superficial and partial-thickness wounds | show 🗑
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| Dressing: Used for minimal drainage | show 🗑
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| Dressing: May reduce pain/pressure | show 🗑
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| Dressing: Can be used as coupling agent for ultrasound | show 🗑
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| Dressing: Minimally adheres to wound | show 🗑
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| show | • Hydrogels
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| Dressing: Cannot be used on wound with significant drainage | show 🗑
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| Dressing: Typically requires second dressing | show 🗑
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| Dressing: Used for varying levels of exudate | show 🗑
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| show | • Foam dressings
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| Dressing: Lack of transparency makes inspection of wound difficult | show 🗑
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| Dressing: Allows visualization of wound | show 🗑
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| Dressing: resistant to shearing forces | show 🗑
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| show | • Transparent films (over time)
• Gauze
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| show | • Transparent films
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| show | • Gauze
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| show | • Gauze
• Alginates
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| show | • Gauze
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| Dressing: Can modify number of layers to accomodate for changing wound status | show 🗑
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| show | • Gauze
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| Dressing: Requires frequent dressing change | show 🗑
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| Dressing: non-occlusive --> increased infection rate | show 🗑
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| Dressing: Used for pressure wounds or venous insufficiency ulcers | show 🗑
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| show | • Hydrogels
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| show | • Alginates
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| Dressing: non-adhering to wound or skin | show 🗑
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| Dressing: cannot be used on wounds with exposed tendon, joint capsule or bone | show 🗑
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| show | • Transparent Film
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| show | • Hydrocolloids (a transparent one)
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| Dressing: Order from most to least occlusive: | show 🗑
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| show | • Alginates
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| Which dressing would you use? pt. with diabetes, pressure ulcer on 1st met. head, Stage IV, necrotic | show 🗑
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| Which dressing would you use? pt. with diabetes, pressure ulcer on 1st met. head, stage IV, infected | show 🗑
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| Dressing: Most moisture retentive to least: | show 🗑
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