NR i224 iEXAM i2
CHPT i48 iSKIN iINTEGRITY iAND iWOUND iCARE
Pressure i ulcers i ilocalized i injury i on i bony i prominence i from i shear i (force i parallel i to
iskin) iand.or ifriction(dragged), imoisture
Ischemia
Blanching i-> ired itones iare iabsent i(not iin idark iskin
ipatients)iOlder iadults, idecreased iconsciousness i @ ihigh irisk
Urine i imaceration i & i skin i breakdown
Use iincontinence icleanser, idry iskin i, imoisture ibarrier
iointmenticontusion i: iclose iwound
laceration i: ijaggediirregular iedges
serous i: iwatery i, iclear
iserasangious i: iwatery, ired
ibloodifrank i: ifresh iblood
purelent i:iinfection i, ithick i, iWBC, ibacteria, itissue idebri
Skeleton i balance isuspension itraction i i shift i weight i while iimmobile,iB ucts
itraction i irestriction iof i movement i (hip ifracture)
Halo i brace ican i ambulate i with i halo i brace
Nutrition
iObservation iofiskin
Ulcers i(upiwalking, iposition ichanging)
Lifting
Clean iskin/continence icare
Elevate ithe
iheelsiRisk
iassessment
Support isurfacesifor ievenidistributions
Stage i1: inonblanchable iredness, iintact iskin i(don’t imassage)
Stage iII: iPartial ithickness i, iskin iloss i(epidermis i& idermis), iblister, iw/o
islough,ia brasion i(ex: ishallow iopen ireddish iw/o islough i(scab ilike) ion iheel iof
ifoot)
Stage iIII: ifull ithickness itissue iloss iwith ifat, islough imay ibe ipresent, idrainage
iand iinfection imay ibe ipresent i, ipurulent idischarge i(thick imilky), ifull ihad ito itoe
Stage iIV: ifull ithickness itissue iwith iexposed ibone, imuscle, ior itendon i,
iescarei( black), iHEAL iBY iSCAR iFORMATION i!
CHPT i48 iSKIN iINTEGRITY iAND iWOUND iCARE
Pressure i ulcers i ilocalized i injury i on i bony i prominence i from i shear i (force i parallel i to
iskin) iand.or ifriction(dragged), imoisture
Ischemia
Blanching i-> ired itones iare iabsent i(not iin idark iskin
ipatients)iOlder iadults, idecreased iconsciousness i @ ihigh irisk
Urine i imaceration i & i skin i breakdown
Use iincontinence icleanser, idry iskin i, imoisture ibarrier
iointmenticontusion i: iclose iwound
laceration i: ijaggediirregular iedges
serous i: iwatery i, iclear
iserasangious i: iwatery, ired
ibloodifrank i: ifresh iblood
purelent i:iinfection i, ithick i, iWBC, ibacteria, itissue idebri
Skeleton i balance isuspension itraction i i shift i weight i while iimmobile,iB ucts
itraction i irestriction iof i movement i (hip ifracture)
Halo i brace ican i ambulate i with i halo i brace
Nutrition
iObservation iofiskin
Ulcers i(upiwalking, iposition ichanging)
Lifting
Clean iskin/continence icare
Elevate ithe
iheelsiRisk
iassessment
Support isurfacesifor ievenidistributions
Stage i1: inonblanchable iredness, iintact iskin i(don’t imassage)
Stage iII: iPartial ithickness i, iskin iloss i(epidermis i& idermis), iblister, iw/o
islough,ia brasion i(ex: ishallow iopen ireddish iw/o islough i(scab ilike) ion iheel iof
ifoot)
Stage iIII: ifull ithickness itissue iloss iwith ifat, islough imay ibe ipresent, idrainage
iand iinfection imay ibe ipresent i, ipurulent idischarge i(thick imilky), ifull ihad ito itoe
Stage iIV: ifull ithickness itissue iwith iexposed ibone, imuscle, ior itendon i,
iescarei( black), iHEAL iBY iSCAR iFORMATION i!
