Download Pressure Ulcers and Wound Care Study Guide and more Exams Nursing in PDF only on Docsity! NR 224 EXAM 2 SKIN INTEGRITY AND WOUND CARE STUDY GUIDE. Download to score Pressure ulcers localized injury on bony prominence from shear (force parallel to skin) and/or friction (dragged), moisture Ischemia Blanching -> red tones are absent (not in dark skin patients) Older adults, decreased consciousness @ high risk Urine maceration & skin breakdown Use incontinence cleanser, dry skin , moisture barrier ointment contusion : close wound laceration : jagged irregular edges serous : watery , clear serasangious : watery, red blood frank : fresh blood purelent : infection , thick , WBC, bacteria, tissue debri Skeleton balance suspension traction shift weight while immobile, Bucts traction restriction of movement (hip fracture) Halo brace can ambulate with halo brace Nutrition Observation of skin Ulcers (up walking, position changing) Lifting Clean skin/continence care Elevate the heels Risk assessment Support surfaces for even distributions Stage 1: nonblanchable redness, intact skin (don’t massage) Stage II: Partial thickness , skin loss (epidermis & dermis), blister, w/o slough, abrasion (ex: shallow open reddish w/o slough (scab like) on heel of foot) Stage III: full thickness tissue loss with fat, slough may be present, drainage and infection may be present , purulent discharge (thick milky), full had to toe Stage IV: full thickness tissue with exposed bone, muscle, or tendon , escare (black), HEAL BY SCAR FORMATION ! Assessment -patient , skin , pressure ulcers, body fluids , pain , head to toe, wounds , drains, culture wound (suspect purulent obtain specimen , never from old drainage), clean infected wound with normal 0.9 saline solution remove skin flora before!, do not irrigate with antiseptic (false negative), obtain sample from cleansed wound (not intact skin) Diagnosis: -risk for infection -acute/chronic pain -impaired mobility -ineffective perfusion -impaired integrity Planning: - prevent pressure ulcers - promote wound healing Implement: - provide w/ high protein - avoid massaging red skin - incontinence management - Q2 turn - 30 degree elevation - wound management (debridement irrigation , wound cleansing of necrotic tissue) - hemoglobin :males 14-18 , females 12-16 (below = low delivery of oxygen to tissue) -WBC 5,000-10,000 NORMAL -theraputic PTT 1.5- 2.5 decrease blood supply to promote clotting & wound healing - control bleeding allow puncture to bleed, don’t remove penetrated object Drain -pin rolls drain comes out passively on it’s own , pin prevents it from slipping back in -JP drain closed suction medical devices, post op drain from surgical site promote healing by draining fluid from wound , prevent pooling of blood, prevent infection , threaded through the wound, LOW PRESSURE fully compressed Dressings - wet to dry gauze remove wound exudate & necrotic tissue (small amounts of exudate), sticks to the wound, - transparent film protects ulcers from moisture and bacteria yet allows oxygen to reach skin, minimized fiction and shear, NO absorption , STAGE 1 - hydrocolloid support healing in clean granulating wound, debris necrotic wounds, forms gel where exudate is absorbed, change as soon as absorption is maxed - hydrogel rehydrate and promote debriment , STAGE 2-4, (necrosis, infection, and need for moist environment NOT dry gangrene) water/glycerin based -alginate STAGE 2-4 pressure uclers, moderate to heavy drainage, moist environment, seaweed, healing and absorption of exudate, packing wound. Large. NOT FOR DRY WOUNDS Tape Tape is used to secure dressing, silicone/non allergenic tape to prevent irritation Secure all sides , adheres to several inches of skin , gentle, exert pressure away from wound , don’t use skin protection (wont resolve) Ties – avoid repeated removal, secure with ties Binders: support to wound, immobilize part of the body, put over dressing Cleaning Cleaning in the direction from least contaminated to most contaminated (center outwards) Gentle friction Evaluate:
