Skin Integrity

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Author:
tatekj
ID:
236191
Filename:
Skin Integrity
Updated:
2013-09-21 15:40:29
Tags:
Exam
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Description:
Nursing
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  1. Skin Integrity
    Explain the nurse interventions for a stage 1 pressure ulcer
    • ⇨Frequent turning
    • ⇨Keep pressure off
    • ⇨special mattress
    • ⇨frequent inspection
    • ⇨pressure relieving devices
  2. Skin Integrity
    Explain the nurse interventions for a stage 2 pressure ulcer
    • ⇨Moist healing dressings (sometimes honey)
    • ⇨bandage cleaned regularly
    • ⇨sterile
  3. Skin Integrity
    Explain the nurse interventions of a stage 3 pressure ulcer
    • ⇨Proteolytic enzymes (form of debridement that eats away dead tissue, doctor order is required)
    • ⇨requires debridement
    • ⇨surgical procedure may be necessary (by doctor)
  4. Skin Integrity
    Explain the nurse interventions for a stage 4 pressure ulcer
    • ⇨pack with iodine goze (it's sterile)
    • ⇨Skin graphing
  5. Skin Integrity
    Describe the characteristics of a stage 1 ulcer
    • ⇨Intact skin
    • ⇨Nonblanchable erythema
    • ⇨if the redness goes way it is not a stage one
  6. Skin Integrity
    Describe the characteristics of a stage 2 ulcer
    • ⇨Partial thickness skin loss in epidermis and or dermis
    • ⇨superficial
    • ⇨clinically described as abrasion, blister or shallow crater
  7. Skin Integrity
    Describe the characteristic of a stage 3 pressure ulcer
    • ⇨Full thickness skin loss
    • ⇨damage or necrosis of subcutaneous tissue
    • ⇨extends down (but not through) underlying fascia.
    • ⇨clinically as deep crater w/or w/out undermining of adjacent tissue
  8. Skin Integrity
    Describe the characteristics of a stage 4 pressure ulcer
    • ⇨Full thickness skin loss w/ extensive destruction  
    • ⇨Damage to muscle, bone, tissue necrosis, and nay supporting structures 
    • ⇨sinus tracts and undermining.
  9. Skin Integrity
    Limitations?
    • ⇨Difficult to determine on dark skin (stage 1)
    • ⇨eschar (dark skin) may need to be debrided because it's hard to determine the stage.
  10. Skin Integrity
    Is reverse staging possible?
    No
  11. Skin Integrity
    Recommendations for those clients determined to be at risk
    • Skin Inspection
    • ⇨At least daily
    • ⇨check bony places
    • ⇨document any findings
    • Protecting Skin
    • ⇨Clean patients up quickly after every incident 
    • ⇨Avoid hot water use
    • ⇨Use lotion 
    • Positioning
    • ⇨Avoid friction
    • ⇨careful with transfers
    • ⇨special pads for wheel chairs, or mattress
    • Nutrition
    • supplements
    • ⇨fluids







  12. Skin Integrity
    Recommendations for those clients determined to be at risk: Documentation, care planning, bed bond, chair bound
    • Documentation
    • ⇨every time you turn
    • ⇨any wounds found
    • Care Plan
    • ⇨Norton scale
    • Bed Bound
    • ⇨repositioning
    • ⇨Use pillows
    • ⇨Try and keep heals off bed
    • ⇨lift devices
    • Chair Bound
    • ⇨Reposition/hr
    • ⇨shift weight

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