Download Wound Care and Skin Integrity: Assessment, Classification, and Healing Process and more Exams Nursing in PDF only on Docsity! FPCC Skin Integrity and Wound Care (Exam 1) Questions with Complete Solution. Why is skin integrity important? - primary defense; protective barrier (against infection); sensory organ; vitamin D synthesis how does a patient get "impaired skin integrity"? - healthcare providers cause it (ex. surgery); accidents, abrasions (animal bites, knives); circulatory problems (problems with arteries or venous circulation); too much pressure (pressure ulcers) by extent - wound assessment, classification; partial thickness (open), full thickness (open), closed by onset and duration - wound assessment, classification; acute (expected to heal quickly), chronic (not resolving quickly) by level of contamination - wound assessment, classification; clean (surgery), contaminated (puncture wounds, does NOT equal infected) by healing process - wound assessment, classification; primary -closed up (does not leave a lot of scarring), secondary - left open (scarring is a lot worse), tertiary - open then closed (not sutured immediately to be sure that it is clean) wound drainage assessment - amount, odor (if odor is present after being cleaned, might be infected), consistency (gel-like, water, sticky), color sanguineous drainage - bright red blood serosanguineous drainage - yellow with a little red surgical wounds assessment - incision (approximated edges, staples, sutures intact, surrounding tissue); presence of drains Penrose - big plastic straw looking; inserted through puncture wound that the surgeon makes on purpose; does NOT come out of incision, but from a separate area Jackson Pratt (JP) - applies suction; can be measured in mL; can be measured without emptying hemlock - smashed down, stays smoothed and sucks out drainage abrasion - traumatic wound; only the top layer of skin is lost; partial thickness wound; most common drainage is serous or sero-sanguenous laceration - traumatic wound; patient cuts themselves on accident; can be partial/full thickness puncture wounds - traumatic wound; small, round, and sometimes deep holes healing of closed laceration - approximated edges, normal inflammation of healing (small swelling around incision as it heals), edges closing 7-10 days (when staples and sutures will come out) venous wound - brownish red, not too deep, fairly shallow, wound bed is beefy red; can have a lot of drainage; if not elevated, can be painful for the patient arterial wound - looks punched out, smooth borders, base of the wound is pale, most commonly seen on distal area of legs development of pressure ulcers - pressure duration/intensity, tissue tolerance (friction, shear, moisture, ability to redistribute pressure) pressure ulcer assessment - where - bony prominences, areas underweight, medical appliance (cast, bladder tube), damp areas, intertriginous (where the skin touches and rubs together) pressure ulcer assessment - what - color of skin (reactive hyperemia, blanching), warmth, edema, change in tissue consistency pressure ulcer assessment - when - on admission, daily, as needed based on assessment findings pressure ulcer assessment - by whom - pressure ulcer assessment should NOT be delegated; RN's are completely responsible for this assessment pressure ulcer assessment - how - Braden scale who is more at risk for pressure ulcers? - decreased sensation, decreased mobility, medical devices, history of skin breakdown, poor nutrition stage I pressure ulcer - intact skin with nonblanchable redness stage II pressure ulcer - partial-thickness skin loss involving epidermis, dermis, or both stage III pressure ulcer - full-thickness tissue loss with visible fat stage IV pressure ulcer - full-thickness tissue loss with exposed bone, muscle, or tendon
