| Scientific Knowledge Base: Skin: Top layer of skin | Epidermis |
| Scientific Knowledge Base: Skin: Inner layer of skin
Collagen | Dermis |
| Scientific Knowledge Base: Skin: Separates dermis and epidermis | Dermal-epidermal junction |
| Scientific Knowledge Base: Pressure sore, decubitus ulcer, or bed sore | Pressure ulcers |
| Scientific Knowledge Base: Pathogenesis: | Pressure intensity
Pressure duration
Tissue tolerance |
| Scientific Knowledge Base: Pathogenesis: Tissue ischemia
Blanching | Pressure intensity |
| Risk factors for pressure ulcer development: | Impaired sensory perception
Impaired mobility
Alteration in LOC
Shear
Friction
Moisture |
| Classification of Pressure Ulcers: Intact skin with nonblanchable redness | Stage 1 |
| Classification of Pressure Ulcers: Partial-thickness skin loss involving epidermis, dermis, or both | Stage 2 |
| Classification of Pressure Ulcers: Full-thickness tissue loss with visible fat | Stage 3 |
| Classification of Pressure Ulcers: Full-thickness tissue loss with exposed bone, muscle, or tendon | Stage 4 |
| Is a quality of living tissue; it is also referred to as regeneration (renewal of tissues | Healing; Wound healing |
| Phases of Wound Healing: | Inflammatory phase
Proliferative phase
Maturation phase |
| Phases of Wound Healing: 1 | Inflammatory phase |
| Phases of Wound Healing: 2 | Proliferative phase |
| Phases of Wound Healing: 3 | Maturation phase |
| Types of wounds: Sharp instrument (e.g. knife or scalpel)
Open wound; deep or shallow; once the edges have been sealed together as part of treatment or healing, the incision becomes a closed wound. | Incision |
| Types of wounds: Blow from a blunt instrument
Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels | Contusion |
| Types of wounds: Surface scrape, either unintentional (e.g. scraped knee from a fall) or intentional (e.g., dermal abrasion to remove pockmarks)
Open wound involving the skin | Abrasion |
| Types of wounds: Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional
Open wound | Puncture |
| Types of wounds: Tissues torn apart, often from accidents (e.g., with machinery)
Open wound; edges are often jagged | Laceration |
| Types of wounds: Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments)
Open wound | Penetrating wound |
| What intention is this? primary or secondary? | Primary intention |
| What intention is this? primary or secondary? | Secondary intention |
| Types of wound Exudate: 1 | Serous exudate |
| Types of wound Exudate: 2 | Purulent exudate |
| Types of wound Exudate: 3 | Sanguineous |
| Types of wound Exudate: 4 | Serosanguineous |
| Types of wound Exudate: 5 | purosanguineous |
| Complications of wound healing: | Hemorrhage- hematoma
Infection
Dehiscence
Evisceration |
| Complications of wound healing: 1: Hematoma | hemorrhage |
| Complications of wound healing: 2: | Infection |
| Complications of wound healing: 3: | Dehiscence |
| Complications of wound healing: 4: | Evisceration |
| Nursing Knowledge Base: Prediction and prevention of pressure ulcers: Braden scale (refer to your book) | Risk assessment |
| Nursing Knowledge Base: Prediction and prevention of pressure ulcers: Economic consequences of pressure ulcers | Prevention |
| Nursing Knowledge Base: Prediction and prevention of pressure ulcers: Prevention: Medicare and medicaid: no additional reimbursement for care related to stage III and IV pressure ulcers that occur during the hospitalization. | Prevention |
| Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: | Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact of wounds |
| Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 1 | Nutrition |
| Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 2 | Tissue perfusion |
| Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 3 | Infection |
| Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 4 | Age |
| Nursing Knowledge Base: Factors influencing pressure ulcer formation and wound healing: 5 | Psychosocial impact of wounds |
| Nursing process: Through the patient's eyes
Skin
Wounds | Assessment |
| Nursing process: Assessment: Skin: | continually assess skin for signs of breakdown and/or ulcer development |
| Nursing process: Assessment: Wounds: 1 | Emergency setting |
| Nursing process: Assessment: Wounds: 2 | Stable setting |
| Nursing process: Assessment: Wounds: 3 | Wound appearance |
| Nursing process: Assessment: Wounds: 4 | Character of wound drainage |
| Nursing process: Assessment: Wounds: 5 | Drains |
| Nursing process: Assessment: Wounds: 6 | Wound closures |
| Nursing process: Assessment: Wounds: 7 | Palpation of wound |
| Nursing process: Assessment: Wounds: 8: Gram stains
Biopsy | Wound cultures |
| Risk for infection
Imbalanced nutrition: less than body requirements
Acute or chronic pain
Impaired physical mobility
Impaired skin integrity
Risk for impaired skin integrity
Ineffective peripheral tissue perfusion
Impaired tissue integrity | Nursing Diagnosis |
| Nursing process: Planning: | Goals and outcomes
Setting priorities
Teamwork and collaboration |
| Nursing process: Planning: Goals and outcomes: plan interventions according to: | Risk for pressure ulcers
Type and severity of the wound
Presence of complications |
| Nursing process: Planning: Setting priorities: | Preventing pressure ulcers
Promoting wound healing |
| Quick quiz : The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges:
A. are approximated
B. Migrate across the incision
C. appear slightly pink
D. slightly overlap each other | Are approximated |
| Implementation: Health promotion: | Prevention of pressure ulcers
Topical skin care and incontinence management
Positioning
Support surfaces |
| Implementation: Acute care: | Dressing Wounds
Wound Irrigation and Packing
Supporting and Immobilizing Wounds
Heat and Cold Applications |
| Implementation: Dressings: | Protects from microorganisms
Aids in homeostasis
Promotes healing by absorbing drainage or debriding a wound
Supports wound site
Promotes thermal insulation
Provides a moist environment |
| Implementation: Types of dressings: | Gauze
Transparent film
Hydrocolloid
Hydrogel
Foam
Composite |
| Implementation: Wound irrigation and packing: Is the washing or flushing out of an area. | An irrigation |
| Implementation: Wound irrigation and packing: is required for a wound irrigation because there is a break in the skin integrity | Sterile technique |
| Implementation: Supporting and immobilizing wounds: | Bandages and binders- serve various purposes
A binder |
| Implementation: Supporting and immobilizing wounds: Is a type of bandage designed for a specific body part; for example, the triangular binder (sling) fits the arm. | A binder |
| Temperature for Hot and Cold Applications: Below 15 degrees Celsius or 59 degrees Fahrenheit
Application: Ice bag | Very cold |
| Temperature for Hot and Cold Applications: 15- 18 degrees Celsius or 59-65 degrees Fahrenheit
Application: Cold pack | Cold |
| Temperature for Hot and Cold Applications: 18-27 degrees Celsius or 65 degrees Fahrenheit
Application: Cold compresses | Cool |
| Temperature for Hot and Cold Applications: 27-37 degrees Celsius or 80-98 degrees Fahrenheit
Alcohol sponge bath | Tepid |
| Temperature for Hot and Cold Applications: 37-40 degrees Celsius or 98-104 degrees Fahrenheit
Warm bath, aquathermia pads | Warm |
| Temperature for Hot and Cold Applications: 40-46 degrees Celsius or 104-115 degrees Fahrenheit
Hot soak, irrigations, hot compressions | Hot |
| Temperature for Hot and Cold Applications: Above 46 degrees Celsius or above 115 degrees Fahrenheit
Hot water bags for adults | Very hot |
| Cleaning skin and drain sites: 1: Clean from least contaminated to the surrounding skin
Use gentle friction
When irrigating, allow the solution to flow from the least to most contaminated area | Basic skin cleaning |
| Cleaning skin and drain sites: | Basic skin cleaning
Cleaning skin and drain sites
Suture care |
| Cleaning skin and drain sites: Irrigation- wound irrigations | Cleaning skin and drain sites |
| Cleaning skin and drain sites: Staple removal
Suture removal | Suture care |
| Cleaning skin and drain sites: Constant, low-pressure vacuum to remove and collect drainage | Drainage evacuation |
| Quick quiz: A positive patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be:
A. it has an odor
B. A culture is negative
C. the edges revel the presence of fluid
D. it shows purulent drainage coming from the incision site | D. It shows purulent drainage coming from the incision site |
| Quick quiz: A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides:
A. an absorbent surface to collect wound drainage.
B. decreased incidence of skin maceration.
C. Protection from the external environment
D. moisture needed for wound healing. | D. moisture needed for wound healing |
| The skin can only tolerate how much temperature? after that, mapaso nata | 48.9 degrees Celsius |
| Rules of 9: Neck and head | 41% |
| Rules of 9: Upper trunk | 9% |
| Rules of 9: Lower trunk | 9% |
| Rules of 9: Upper limbs | 41% |
| Rules of 9: Lower limbs | 9% |
| Rules of 9: genital area | 1% |
| Burn Depth Classification: Epidermis only
Appearance: Erythema, blanches with pressure
Sensation: intact, mild to moderate pain
Healing:
3-6 days without scarring | First degree |
| Burn Depth Classification: Epidermis and superficial dermis, skin appendages intact
Appearance: Erythema, blister's moist, elastic, blanches with pressure
Sensation: intact, severe pain
Healing: 1-3 weeks, scarring unusual | Second degree: superficial |
| Burn Depth Classification: Epidermis and most dermis, most skin appendages destroyed
Appearance: White appearing with erythematous areas dry, waxy, less elastic, reduced blanching to pressure
Sensation: Decreased, may be less painful
>3 weeks, often with scarring and contractures | Second degree: Deep |
| Burn Depth Classification: Epidermis and all of dermis, destruction of all skin appendages
Appearance: White, charred, tan, thrombosed vessels, dry and leathery, does not blanch
Sensation: Anesthetic, not painful (although surrounding areas of second-degree burns are painful)
Healing: Does not heal, sever scarring and contractures | Third-degree |
| Quick quiz: What electrolyte imbalance occur in Burns?
a. Hypocalemia
b. Hyperkalemia | b. Hyperkalemia |
| A 60 year old man has been burned in a house fire. He has partial and full thickness burns to the anterior surface of his neck, chest, and abdomen. The approximate percentage of burn injury sustained is? | 1% anterior surface of his neck
9% anterior surface of his chest
9% and anterior surface of his abdomen
total: 19% |
