NPTE: Integumentary (scorebuilder 2008)
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| Exudate classification: presents as clear, light color with a thin, watery consistency | show 🗑
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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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| show | seropurulent
• may be an early warning sign of impending infection.
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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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| show | deep ulcer with osteitis, abscess or osteomyelitis.
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| Wagner Grade 4 | show 🗑
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| Wagner Grade 5 | show 🗑
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| show | involves only outer epidermis. area may be red with slight edema. no scarring.
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| Superficial partial-thickness burn | show 🗑
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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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| show | the area of less severe injury that possesses reversible damage and surrounds the zone of coagulation.
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| Definition: zone of hyperemia | show 🗑
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| Rule of nines: • Head and neck | show 🗑
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| Rule of nines: • Anterior trunk | show 🗑
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| show | 18%
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| show | 9%
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| show | 9%
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| show | 1%
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| Rule of nines: • Bilateral anterior LE | show 🗑
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| Rule of nines: • Bilateral posterior LE | show 🗑
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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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| show | • silver sulfadiazine
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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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| Topical agents used in burn care: • non-allergenic | show 🗑
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| show | • silver sulfadiazine
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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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| Topical agents used in burn care: • may be used with or without occlusive dressing | show 🗑
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| show | • gentamicin
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| Topical agents used in burn care: • bacteriocidal | show 🗑
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| show | • silver sulfadiazine
• silver nitrate
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| Topical agents used in burn care: • discolors, making assessment difficult | show 🗑
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| show | • silver nitrate
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| show | • silver nitrate
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| Topical agents used in burn care: • not effective against pseudomonas | show 🗑
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| show | • povidone-iodine
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| Topical agents used in burn care: • painful application | show 🗑
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| Topical agents used in burn care: • may cause metabolic acidosis | show 🗑
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| show | • mafenide acetate
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| show | • mafenide acetate
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| show | • gentamicin
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| show | • gentamicin
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| show | • gentamicin
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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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| show | permanent skin graft taken from a donor site on the pt.'s body
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| show | temporary skin graft taken from another species.
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| show | skin graft that is altered to create a mesh-like appearance in order to cover a larger surface area.
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| show | skin graft is transferred directly from the donor site to the recipient site.
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| definition: split-thickness skin graft | show 🗑
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| definition: full-thickness skin graft | show 🗑
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| burn location: anticipated deformity: • anterior neck | show 🗑
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| show | soft collar, molded collar, philadelphia collar
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| burn location: splinting type: • anterior chest and axilla | show 🗑
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| show | shoulder adduction, extension, and medial rotation
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| burn location: anticipated deformity: • elbow | show 🗑
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| burn location: splinting type: • elbow | show 🗑
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| burn location: anticipated deformity: • hand | show 🗑
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| burn location: splinting type: • hand | show 🗑
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| show | flexion and adduction
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| burn location: splinting type: • hip | show 🗑
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| burn location: anticipated deformity: • knee | show 🗑
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| burn location: splinting type: • knee | show 🗑
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| show | plantarflexion
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| show | posterior foot drop splint, posterior ankle conforming splint, anterior ankle conforming splint
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| show | selective
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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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| selective or non-selective debridement? • hydrotherapy | show 🗑
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| arterial or venous insufficiency ulcer? • location: lower one-third of leg | show 🗑
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| arterial or venous insufficiency ulcer? • location: toes, web spaces | show 🗑
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| arterial or venous insufficiency ulcer? • location: dorsal foot | show 🗑
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| show | arterial
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| show | venous insufficiency
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| arterial or venous insufficiency ulcer? • appearance: smooth edges, well defined | show 🗑
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| show | arterial
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| arterial or venous insufficiency ulcer? • appearance: tend to be deep | show 🗑
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| arterial or venous insufficiency ulcer? • appearance: irregular shape | show 🗑
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| show | venous insufficiency
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| arterial or venous insufficiency ulcer? • pain: severe | show 🗑
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| arterial or venous insufficiency ulcer? • pain mild to moderate | show 🗑
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| arterial or venous insufficiency ulcer? • pedal pulse: diminished or absent | show 🗑
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| arterial or venous insufficiency ulcer? • pedal pulse: normal | show 🗑
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| show | arterial
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| arterial or venous insufficiency ulcer? • increased edema | show 🗑
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| arterial or venous insufficiency ulcer? • skin temperature: decreased | show 🗑
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| arterial or venous insufficiency ulcer? • skin temperature: normal | show 🗑
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| show | arterial
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| show | arterial
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| show | arterial
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| arterial or venous insufficiency ulcer? • tissue changes: flaking | show 🗑
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| arterial or venous insufficiency ulcer? • tissue changes: dry skin | show 🗑
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| show | venous insufficiency
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| show | venous insufficiency
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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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| show | • Hydrocolloids
• Hydrogels
• Foam Dressings
• Transparent film
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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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| Dressing: Provides moderate absorption | show 🗑
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| Dressing: Does not require a second layer | show 🗑
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| show | • Hydrocolloids
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| show | • Hydrocolloids
• Adhesive form of Foam Dressing
• Adhesive form of Transparent film
• Gauze
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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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| show | • Hydrogels
• Transparent films
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| show | • Hydrogels
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| Dressing: Can be used as coupling agent for ultrasound | show 🗑
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| show | • Hydrogels
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| show | • Hydrogels
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| show | • Hydrogels
• Transparent Films
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| Dressing: Typically requires second dressing | show 🗑
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| show | • Foam dressings (up to moderate level of absorption)
• Gauze
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| show | • Foam dressings
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| show | • Foam dressing
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| show | • Transparent films
• Some Hydrocolloids
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| show | • Transparent films
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| show | • Transparent films (over time)
• Gauze
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| show | • Transparent films
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| Dressing: Can be used for wet-to-wet, wet-to moist, or wet-to-dry debridement | show 🗑
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| show | • Gauze
• Alginates
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| Dressing: Can be used alone or in combination with other dressings or topical agents | show 🗑
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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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| show | • Gauze
• Alginates
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| show | • Gauze
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| Dressing: Used for pressure wounds or venous insufficiency ulcers | show 🗑
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| Dressing: moisture-retentive | show 🗑
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| Dressing: High absorptive capacity | show 🗑
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| show | • Alginates
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| show | • Alginates
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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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| show | • Hydrocolloids
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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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| show | • Alginates • Semi-permeable foam • Hydrocolloids • Hydrogels • Semi-permeable films
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