Integumentary System & Wound Care
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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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| What type of objective data would you collect on the integumentary system? | show 🗑
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| show | feel for temp, push down to see if skin blanches
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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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| What tool can you use to keep a close eye on a suspicious lesion to help prevent neoplasms? | show 🗑
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| How do you treat fungal lesions? | show 🗑
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| How do you treat viral lesions? | show 🗑
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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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| show | Staph infections, MRSA, impetigo,
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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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| show | Pressure or pressure & shear
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| Explain Stage I of pressure ulcers. | show 🗑
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| Explain Stage II of pressure ulcers | show 🗑
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| Explain Stage III of pressure ulcers | show 🗑
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| show | full thickness loss
bone, muscle, tendon exposed
slough/eschar can be present
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| Explain Unstageable stage of pressure ulcers | show 🗑
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| What part of the body would you want to leave Eschar? | show 🗑
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| show | purple or maroon
blood filled blister due to damage to underlying soft tissue or shear or pressure
must heal on its own
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| show | epithelialization-epidermal cells reproduce and migrate across the surface of the wound
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| In the wound healing process what happens to a full thickness wound? | show 🗑
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| show | Medical History
Current Meds
Allergies
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| What would be objective data for wound care? | show 🗑
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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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| show | 1. Hemostasis
2. Inflammatory Phase
3. Proliferative Phase
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| What are the phases of wound healing with a full thickness wound? | show 🗑
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| What is Hemostatis? | show 🗑
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| show | 2nd phase of wound healing
-swelling, dialated blood vessels, leukocytes rush to site
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| What is Proliferative Phase? | show 🗑
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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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| What is a priority when checking a wound? | show 🗑
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| show | Sanguineous
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| show | Purulent
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| What type of fluid is clear liquid? | show 🗑
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| show | Seroussanguineous
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| What is debridement? | show 🗑
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| show | -protection
-absorb drainage
-keep wound bed moist
-debridement
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| What is the purpse of transparent dressing? | show 🗑
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| show | dauze with hyrdogel in it
cooling gel helps with pain
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| show | -more cost effective
-keeps moisture in
-doesn't absorb exudate
-can stay on up to 3 days
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| show | antimicrobial factors
good for infected wounds
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| What is the purpose of Foam dressing? | show 🗑
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| show | good for wounds with lots of drainage
good for packing
helps debride the wound
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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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| What is dehiscence? | show 🗑
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| What is evisceration? | show 🗑
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| show | a delay in the closure of the wound to get bacteria out
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| The nurse knows that 1st day surgical site that has erythema is normal or abnormal? How about on day 5-6? | show 🗑
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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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