Fundamentals of Nursing: Skin Integrity and Wound Care

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Functions of the skin
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Protection, body temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elimination
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Phases of wound healing
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Hemostasis Inflammatory Proliferation Maturation
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Factors affecting the skin
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Dehydration, malnutrition, diabetes, bedrest, casts, application of heat and cold, and age
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Intentional wound
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Result of a planned invasive therapy or treatment
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Unintentional wound
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Accidental, such as stabbing or gunshot
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Open wound
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Occurs from intentional or unintentional trauma; skin is broken
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Closed wound
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Results from a blow, force, or strain caused by trauma; skin is not broken
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Wound repair occurs by
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Primary, secondary, and tertiary intention
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Primary intention
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Well approximated, minimal tissue loss, and approximated edges
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Example of primary intention
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Surgical incision
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Secondary intention
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Infected primary intention Large, open wound, and often contaminated Take longer to heal
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Example of secondary intention
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Burns
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Tertiary intention
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Wounds opened for days Allow for edema and infection
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Hemostatsis
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Occurs immediately after the initial injury Blood vessels constrict and blood clootting begins
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Exudate
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Liquid formed during hemostasis once blood vessels dialate and capillary permeability increases
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The accumulation of exudate causes
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Swelling and pain
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Inflammatory phase
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Last about 4 to 6 days White blood cells move toward wound
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Inflammatory phases caused
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Pain, heat, swelling, and redness; sometimes a mild temperature
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Proliferation phase
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Last for several weeks Granulation tissue forms
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Granulation tissue
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Forms the foundation for scar tissue development
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Maturation phase
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Begins 3 weeks after initial injury and continues for months Scar is formed
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Wound complications
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Infections, hemorrhage, dehiscence, evisceration, and fistula
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Dehiscence
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Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed
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Evisceration
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Wound completely separated with protrusion of viscera through the incisional area
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Most serious complication of dehiscence
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Evisceration
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Fistula
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Abnormal passage from an internal organ to the outside of the body from one internal organ to another
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Psychological effects of wounds
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Pain, anxiety, fear, and change in body image
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Pressure ulcer
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Wound with localized area of tissue necrosis
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Ischemia
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Deficiency of blood in a particular area
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Pressure ulcers are commonly classified according to
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Six stages
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Stages of pressure ulcers
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Suspected Stage 1, 2 3, and 4 Unstagable
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Eschar
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Thick, leathery scab or dry crust that is necrotic
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Nutritional status
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Albumin level Prealbumin level Body weight
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Albumin level
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< 3.2 mg/dL
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Prealbumin level
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< 19 mg/dL
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Body weight
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decrease of > 15%
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Wound assessment
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Inspect and palpate
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Inspect for
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Sight and smell
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Palpate for
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Appearance, drainage, odor, and pain
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Wound drainage
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Serous Sanguineous Serosanguineous Purulent
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Serous drainage
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Composed primarily of clear portion of blood; clear and watery
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Sanguineous drainage
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Consists of large numbers of RBCs and looks like blood
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Serosanguineous draingage
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Mixture of serum and RBC; light pink
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Purulent drainage
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Made of WBC, liquefied dead tissue, and living and dead bacteria; thick, musty, and various in color (dark yellow or green)
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Red wounds
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Are in proliferate stage of healing
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Yellow wounds
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Indicate presence of exudate
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Black wounds
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Indicate the presence of eschar
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Presence of infection is suspected if wound is
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Swollen, deep red, hot, draining, has an odor, and/or its edges are dehisenced
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Examples of wound dressings
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Hydrocolloid, hydrogel, and alginates
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Hydrocolloids
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Minimal to moderate absorption Facilitate autolytic debridement May be left for 3 to 7 days
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Hydrogels
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Minimal absorption Facilitate autolytic debridement Reduce pain
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Alginates
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Facilitate autolytic debridement Requires secondary dressing Can be left in place for 1 to 3 days
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Types of draining systems
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Open and closed
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Open draining systems
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Penrose
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Closed draining systems
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Jackson-Pratt and Hemovac
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Precaution used in wound care
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Standard
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Would cleansing
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Clean from top to bottom at the incision with 0.9% sodium chloride
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Purpose of wound dressing
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Provides physical, psychological, and aesthetic comfort Removes necrotic tissue and absorbs drainage Prevents, eliminates, and controls infection Maintains a moist wound environment Protects wound from further injury Protect skin surrounding wound
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Types of wound dressings
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Telfa, gauze, and transparent
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Types of binders
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Straight, T-binder, and sling
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Straight binder
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Used for chest and abdomen
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T-binder
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Used for rectum, perineum, and groin area
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Sling
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Used to support an arm
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Montgomery straps
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Protect the patient’s skin
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Types of pressure ulcers
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Decubitus, pressure sore, and bed sore
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Stage I
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Nonblancable erythema
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Stage II
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Partial-thickness skin loss
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Stage III
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Full-thickness skin loss
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Stage IV
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Full-thickness skin loss with extensive destruction
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Unstagable
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Base of ulcer covered by slough and or eschar in wound bed
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Risk assessment scales
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Norton and Braden
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19-23
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No risk
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15-18
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Mild risk
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13-14
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Moderate risk
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10-12
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High risk
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9 or lower
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Very high risk
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Measurement of a pressure ulcer
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Size, depth, and tunneling
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Would culture is a
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Sterile procedure
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Nutritional needs to wound healing
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Protein, vitamin C, vitamin A, and Zinc
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Factors affecting hot and cold treatment response
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Method and duration, degree of hot and cold, age, physical condition, and amount of body surface
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Effects of applying heat
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Dilates peripheral blood vessels, increases tissue metabolism, reduces blood viscosity, reduces muscle tension, and helps relieve pain
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Ostomy care
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Replace bag every 3-7 days Assess stoma and skin
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Cut opening of stoma appliance
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1/8 larger
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Suture removal
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Sterile technique
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Staple removal must have
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Physician order

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