Fundamentals Ch. 36 Skin and Wound Care

  1. Describe factors affecting skin integrity.
  2. Identify clients at risk for pressures.
  3. Describe the four stages of pressure ulcer development.
  4. Differentiate primary and secondary wound healing.
  5. Describe the three phases of wound healing.
  6. Identify three major types of wound exudate.
  7. Identify the main complications of and factors that affect wound healing.
  8. Identify assessment data pertinent to skin integrity, pressure sites, and wounds.
  9. Identify nursing diagnoses associated with impaired skin integrity.
  10. Identify essential aspects of planning care to maintain skin integrity and promote wound healing.
  11. Discuss measures to prevent pressure ulcer formation.
  12. Describe nursing strategies to treat pressure ulcers, promote wound healing, and prevent complications of wound healing.
  13. Identify purposes of commonly used wound dressing materials and binders.
  14. Identify essential steps of obtaining wound specimens, applying dressings, and irrigating a wound.
  15. Identify physiologic responses to and purposes of heat and cold.
  16. Describe methods of applying dry and moist heat and cold.

11 cards   |   Total Attempts: 185
  

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Cards In This Set

Front Back
Describe stage I of pressure ulcers
Nonblanchable erythema signaling potential ulceration
Describe stage II of pressure ulcers
Partial-thickness skin loss involving epidermis and possible dermis
Describe stage III Pressure Ulcers
Full-thickness skin loss involving damage or necrosis of subcutanwous tissue
Describe stage IV Pressure Ulcers
Full-thickens skin loss with tissue necrosis ro damage to muscle, bone, or supporting structures
When assessing a pressure ulcer, how should you document the location of the decubitis?
Location of the ulcer related to a bony prominence and the size of the ulcer in centimeters including length (head to toes) width (side to side) and depth
What are some goals in planning for a client with decubitits?
Risked for impaired skin integrity: maintain skin intergrity, avoid or reduce risk factors

Impaired skin integrity: progressive wound healing, regain intact skin
What are fibrin sealants?
Concentrated human clottable proteins used to stop bleeding
What type of wound drain is a penrose?
This is soft and flexible, it is not a collection device and is not sutured into place
Describe the rebound phenomenon
Heat produces maximum vasodilation in 20-30 min, after that vasoconstriction occurs

With cold, once skin reaches 60F/15C vasodilation begins
On the Braden Scale for predicting pressure ulcers, what is the highest score, and what score indicates a risk
23 is the highest, and any score below 18 indicates risk
On the Norton's Pressure Area Risk Assessment Form Scale, what is the highest score, and what score acts as an indicator of risk?
Highest score is a 24, and a score of 15 or 16 are indicators of rsik