NR 224 EXAM 2 (LATEST, 2021): CHAMBERLAIN COLLEGE OF NURSING (VERIFIED ANSWERS, DOWNLOAD TO SCORE A)

Document Content and Description Below

NR 224 EXAM 2 CHPT 48 SKIN INTEGRITY AND WOUND CARE Pressure ulcers  localized injury on bony prominence from shear (force parallel to skin) and.or friction(dragged), moisture Ischemia Blanchin... g -> 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, pink, blood tinged frank : fresh blood purelent : infection , thick , WBC, bacteria, tissue debri , odor 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 assessmentSupport 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 ! Unstageable : depth is unknown, completely obscured by slough (yellow, tan , green) or escar (tan to black), can be a III or a IV, suspected deep tissure injury, purple or marron, localized, intact skin, blood filled blister Assess the type of tissue  amount, appearance(color), viable/nonviable tissue, granulation tissue (red moist new blood vessels  healing) , slough must be removed by skilled tech or wound dressing Protein is important for skin (wound healing) albumin level 3.5 to 5 (less than 3.5 means lacking protein  skin breakdown) hydrogel/hydrocolloid dressing (moisture) provided for healing low air therapy units decrease pressure Q2 turns! Healing:Nutrition Perfusion Infection Age Psychosocial Primary intention  approximated (surgical  by stables) Secondary intention not approximated Complications of healing Hemorrhage Hematoma Infection  2nd most HAI, microorganisms invading wound tissue Urithemia , increased wound drainage, warmth, pain, edema, fever, tenderness, color , elevated WBCs, inflamed edges, odorous, Dehiscence  partial or total separation of wound layer Evisceration  visceral organ from total separation of wound , EMERGENCY, do not attempt to put organ back in , wet sterile gauges over the site , inform surgical team, observe for shock, supine, knees and hip should be bent, vital signs Q5min, prepare client put in trandelgenberg Braden scale  risk factors on 6 subscales 0.9 % NA doesn’t kill the good cells  promote healing  noncytotoxic [Show More]

Last updated: 1 year ago

Preview 1 out of 20 pages