Integumentary System & Wound Care
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| show | 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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| show | 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? | show 🗑
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| show | Nonmelanoma:
1. Basal Cell Carcinoma
2. Squamous Cell Carcinoma
3. Malignant Melanoma
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| show | 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. | show 🗑
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| Which neoplasm can be found in eyes, gut, bowel and is extremely serious and deadly? | show 🗑
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| show | A-asymmetry
B-border
C-color
D-diameter (if >6mm, serious!!!)
E-evolving (changing color, shape, etc)
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| show | keep area dry and away from moisture
use topical antifungal ointment
take oral antifungal meds
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| show | antiviral tx
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| How do you treat bacterial lesions? | show 🗑
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| Give an example of fungal lesions | show 🗑
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| Give an example of viral lesions | show 🗑
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| Give 3 examples of bacterial lesions | show 🗑
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| How do you treat allergic conditions of integumentary? | show 🗑
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| What is a pressure ulcer? | show 🗑
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| What causes a pressure ulcer? | show 🗑
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| Explain Stage I of pressure ulcers. | show 🗑
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| show | partial thickness loss
dermis damaged (break in skin)
shallow open ulcer
no slough
can be a blister with clear fluid
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| show | full thickness loss
subcutaneous tissue damage (no bone, tendon,muscle exposed)
tunneling
undermining
possible slough
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| show | full thickness loss
bone, muscle, tendon exposed
slough/eschar can be present
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| show | 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? | show 🗑
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| Explain Suspected Deep Tissue Injury (DTI) in pressure ulcer stages. | show 🗑
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| show | epithelialization-epidermal cells reproduce and migrate across the surface of the wound
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| show | granulation tissue develops (proliferation stage), as its produced it fills with CT
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| show | Medical History
Current Meds
Allergies
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| show | dimensions & location
tissue
exudate (drainage)
surrounding tissue
pain level
neurovascular
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| How would you assess a neurological or vascular injury? | show 🗑
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| What is a partial thickness wound? AKA Primary intention | show 🗑
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| What is a full thickness wound? AKA Secondary Intention | show 🗑
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| What are the phases of wound healing with a partial thickness wound? | show 🗑
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| show | 1. Hemostatis
2. Inflammatory Phase
3. Proliferative Phase
4. Maturation
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| show | 1st phase of wound healing
-stop the blood flow to that area
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| What is Inlammatory Phase? | show 🗑
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| show | 3rd phase of wound healing
-new skin cells grow
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| show | -3 days
-wet, moist surface
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| What is Maturation? | show 🗑
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| What does granualtion indicate? | show 🗑
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| show | 80%
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| show | Checking the pulse (for perfusion)
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| What type of fluid is bright red blood? | show 🗑
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| What type of fluid is pustular drainage (green, milky)? | show 🗑
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| show | Serous
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| show | Seroussanguineous
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| show | removing slough
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| What is the purpose of dressing a patients wound? | show 🗑
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| show | -keep it moist, but is breathable but doesn't allow baceria to get in
-often used in IV sites
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| show | dauze with hyrdogel in it
cooling gel helps with pain
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| What is the purpose of Hydrocolloid dressing? | show 🗑
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| show | antimicrobial factors
good for infected wounds
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| show | good absorption of wounds with lots of drainage
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| What is the purpose of Calcium Alginate? | show 🗑
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| show | 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? | show 🗑
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| What would be some nursing interventions for integumentary? | show 🗑
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| show | wet dressings
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| show | accidental seperation of wound edges
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| show | Protrusion of internal organs through an open wound
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| What is teriary intention? | show 🗑
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| show | -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? | show 🗑
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