Integumentary System & Wound Care
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| 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
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| 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
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| 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
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| Name 3 types of Neoplasms and their category. | Nonmelanoma:
1. Basal Cell Carcinoma
2. Squamous Cell Carcinoma
3. Malignant Melanoma
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| Which neoplasm is the least deadly and most common? | Basal Cell Carcinoma
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| Which neoplasm can occur due to exposure to sun and smoking, and isn't too common, but CAN cause death. | Squamous Cell Carcinoma
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| Which neoplasm can be found in eyes, gut, bowel and is extremely serious and deadly? | Malignant Melanoma
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| 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)
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| How do you treat fungal lesions? | keep area dry and away from moisture
use topical antifungal ointment
take oral antifungal meds
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| How do you treat viral lesions? | antiviral tx
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| How do you treat bacterial lesions? | antibiotics (oral, topical)
heat vasodialtes, thus increasing leukocyte to area (to fight it off)
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| Give an example of fungal lesions | Tinea capitis
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| Give an example of viral lesions | plantar warts
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| Give 3 examples of bacterial lesions | Staph infections, MRSA, impetigo,
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| How do you treat allergic conditions of integumentary? | antihistamines, topical creams, epinephrin (epi pen-if severe)
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| What is a pressure ulcer? | localized injury to skin and/or underlying tissue, usually over a bony prominence
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| What causes a pressure ulcer? | Pressure or pressure & shear
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| Explain Stage I of pressure ulcers. | damage in epidermis (redness-no break)
will not blanch when applying pressure
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| 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
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| Explain Stage III of pressure ulcers | full thickness loss
subcutaneous tissue damage (no bone, tendon,muscle exposed)
tunneling
undermining
possible slough
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| Explain Stage IV of pressure ulcers | full thickness loss
bone, muscle, tendon exposed
slough/eschar can be present
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| Explain Unstageable stage of pressure ulcers | full thickness loss
base of ulcer covered with slough &/or eschar
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| What part of the body would you want to leave Eschar? | Heels
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| 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
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| In the wound healing process what happens to a partial thickness wound? | epithelialization-epidermal cells reproduce and migrate across the surface of the wound
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| In the wound healing process what happens to a full thickness wound? | granulation tissue develops (proliferation stage), as its produced it fills with CT
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| What would be subjective data for wound care? | Medical History
Current Meds
Allergies
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| What would be objective data for wound care? | dimensions & location
tissue
exudate (drainage)
surrounding tissue
pain level
neurovascular
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| 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
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| What is a partial thickness wound? AKA Primary intention | Sliced, clean incision, not extremely damaged
Ex:slicing bread with a knife
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| What is a full thickness wound? AKA Secondary Intention | Torn tissue, lots of damage
Ex:tearing bread apart
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| What are the phases of wound healing with a partial thickness wound? | 1. Hemostasis
2. Inflammatory Phase
3. Proliferative Phase
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| What are the phases of wound healing with a full thickness wound? | 1. Hemostatis
2. Inflammatory Phase
3. Proliferative Phase
4. Maturation
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| What is Hemostatis? | 1st phase of wound healing
-stop the blood flow to that area
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| What is Inlammatory Phase? | 2nd phase of wound healing
-swelling, dialated blood vessels, leukocytes rush to site
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| What is Proliferative Phase? | 3rd phase of wound healing
-new skin cells grow
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| Approimately how long until the proliferative phase? It requires what to heal? | -3 days
-wet, moist surface
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| What is Maturation? | 4th phase of wound healing (only full thickness)
-wound matures, scar tissue forms
appx: 3wks-2yrs
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| What does granualtion indicate? | new tissue forming
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| Once the skin is damaged, about how much does it go back to the way it was before? | 80%
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| What is a priority when checking a wound? | Checking the pulse (for perfusion)
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| What type of fluid is bright red blood? | Sanguineous
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| What type of fluid is pustular drainage (green, milky)? | Purulent
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| What type of fluid is clear liquid? | Serous
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| What type of fluid is a mix of clear fluid and pinkish, orange liquid? | Seroussanguineous
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| What is debridement? | removing slough
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| What is the purpose of dressing a patients wound? | -protection
-absorb drainage
-keep wound bed moist
-debridement
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| 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
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| What is the purpose of Hydrogel dressing? | dauze with hyrdogel in it
cooling gel helps with pain
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| What is the purpose of Hydrocolloid dressing? | -more cost effective
-keeps moisture in
-doesn't absorb exudate
-can stay on up to 3 days
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| What is the purpose of Silver Dressing? | antimicrobial factors
good for infected wounds
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| What is the purpose of Foam dressing? | good absorption of wounds with lots of drainage
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| What is the purpose of Calcium Alginate? | good for wounds with lots of drainage
good for packing
helps debride the wound
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| What are some nursing diagnoses related to Integumenatry? | 1. Impaired Skin Integrity
2. Impaired Tissue Integrity
3. Risk for impaired Skin Integrity
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| 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
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| 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
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| List one way to decrease pruritus? | wet dressings
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| What is dehiscence? | accidental seperation of wound edges
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| What is evisceration? | Protrusion of internal organs through an open wound
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| What is teriary intention? | a delay in the closure of the wound to get bacteria out
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| The nurse knows that 1st day surgical site that has erythema is normal or abnormal? How about on day 5-6? | -normal
-abnormal
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| 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
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