NR I224: IFundamentals IExam I2
Chapter I48
Roles Iof Iskin
• Protective Ibarrier Iagainst Idisease-causing Iorganisms
• Sensory Iorgan Ifor Ipain, Itemperature, Iand Itouch
• Vitamin ID
I synthesisILayers Iof Ithe Iskin
• Epidermis
o Basal Ilayer: Icells Idivide, Iproliferate, Iand Imigrate Itoward Ithe
IepidermalIs urface
• Secondary Iintention: Ihealthy, Ipink, Igranulating Itissue Ihealing Ifrom Ibottom Iup; Ikeep
moist. INeed Ito Ipack Iotherwise Itop Ilayer Iheals Ibefore Iand Iinfection Ican
I occurISkin Iintegrity
• Patient Ieducation
• Pressure Iulcers: Irelated Ito Ipressure Iintensity, Ipressure Iduration, Iand Itissue
Itolerance; Iblanching Idoes Inot Ioccur Iwith Ipressure Iulcers; IAlso Iknown Ias
IpressureIs ore, Idecubitus Iulcer, Ior Ibed Isore
o Risk Ifactors Ifor Idevelopment
▪ Impaired Isensory Iperception
▪ Impaired Imobility
▪ Alteration Iin ILOC
▪ Shear
▪ Friction
▪ Moisture
o Staging
▪ 1: Iintact Iskin Iwith Inonblanchable Iredness
▪ 2: Ipartial-thickness Iskin Iloss Iinvolving Iepidermis, Idermis, Ior Iboth
▪ 3: Ifull-thickness Itissue Iloss Iwith Ivisible Ifat
▪ 4: Ifull-thickness Itissue Iloss Iwith Iexposed Ibone, Imuscle, Ior Itendon
▪ Unstageable/unclassified: Ifull-thickness Ior Itissue Iloss-
IdepthIunknown. ICompletely Icovered Iby Islough Iand/or
Ieschar.
▪ Suspected Ideep Itissue Iinjury: Idepth Iunknown; Ipurple Ior Imaroon
localized Iarea Iof Idiscolored Iintact Iskin Ior Iblood-filled Iblister Idue Ito
Idamage Iof Iunderlying Isoft Itissue Ifrom Ipressure Iand/or Ishear. IMay
IbeIpainful, Ifirm, Imushy, Iboggy, Iwarmer/cooler.
o Process Iof Iwound Ihealing
▪ Primary Iintention: Ii.e. Isurgical Iincision Iwith Ilittle Itissue Iloss; Ilow Irisk
IofIinfection, Iedges Iare Iapproximated Ior Iclosed, Ihealing Ioccurs Iquickly
Iwith Iminimal Iscar Iformation
▪ Secondary Iintention: Ii.e. Ipressure Iulcer; Iwound Iwith Iloss Iof Itissue, Ileft
open Iuntil Ifilled Iwith Iscar Itissue; Itakes Ilonger Ito Iheal; Igreater IchanceIof
Iinfection
▪ Stage I3 Iis Iresolved Ior Iclosed Ibut Inever Ihealed
▪ Complications
, • Hemorrhage I(hematoma): Ilocalized Icollection Iof
IbloodIunderneath Ithe Itissue
• Infection
• Dehiscence: Ithe Ipartial Ior Itotal Iseparation Iof Iwound Ilayers;
Ipatient Iat Irisk Ifor Ipoor Iwound Ihealing Iis Iat Irisk Ifor Idehiscence
• Evisceration: IProtrusion Iof Iorgans Ifrom Iwound; ITHIS IIS IAN
EMERGENCY, I IMMEDIATELY IPLACE IDAMP
ISTERILEIGAUZE IOVER ISITE IAND ICONTACT
ISURGICAL ITEAM.
o Prevention/ INursing Iinterventions
▪ No Iadditional Ireimbursement
▪ Good Inutrition
▪ Mechanical Iloading Iand Isupport Idevices
• Repositioning Iproperly Iand Ifrequently
o At Ileast Ievery I2 Ihrs
o 30 Idegree Ilateral Iposition
• Use Iof Itherapeutic Isurfaces
▪ Skin Icare Iand Imanagement Iof Iincontinence
• Keep Iskin Iclean Iand Idry
▪ Pain Icontrol
▪ Education
o Factors Iinfluencing Ipressure Iulcer Iformation Iand Iwound Ihealing
▪ Nutrition
▪ Tissue Iperfusion
▪ Infection
▪ Age
▪ Psychosocial Iimpact Iof Iwounds
o Important Inutrients Iand Ilab Ivalues
▪ Vitamins IAI& IC
▪ Calories: I1500 Ikcal/day
▪ Proteins
o Braden Iscale
▪ 6 Isubscales
• Sensory Iperception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction/shear
▪ Higher Iscore I Ilower Irisk I(6 Ito I23 Ipoint Iscale)
• Goals Ifor Iskin Iintegrity
o AIgood Igoal: Ipressure Iwill Ibe Ireduced Ito Isacral Iarea, Iand Ithe Iwound
IwillIs how Imovement Itoward Ihealing Iin I1 Iweek
• Wounds
o Wash Iwounds Iwith Inormal Isaline Ibefore Iculturing
o Important Ito Iidentify Ithe Isupport Isurface Ithat Iwould Ibe Iappropriate
ItoIdecrease Ipressure Ion Ipatient Iskin
Chapter I48
Roles Iof Iskin
• Protective Ibarrier Iagainst Idisease-causing Iorganisms
• Sensory Iorgan Ifor Ipain, Itemperature, Iand Itouch
• Vitamin ID
I synthesisILayers Iof Ithe Iskin
• Epidermis
o Basal Ilayer: Icells Idivide, Iproliferate, Iand Imigrate Itoward Ithe
IepidermalIs urface
• Secondary Iintention: Ihealthy, Ipink, Igranulating Itissue Ihealing Ifrom Ibottom Iup; Ikeep
moist. INeed Ito Ipack Iotherwise Itop Ilayer Iheals Ibefore Iand Iinfection Ican
I occurISkin Iintegrity
• Patient Ieducation
• Pressure Iulcers: Irelated Ito Ipressure Iintensity, Ipressure Iduration, Iand Itissue
Itolerance; Iblanching Idoes Inot Ioccur Iwith Ipressure Iulcers; IAlso Iknown Ias
IpressureIs ore, Idecubitus Iulcer, Ior Ibed Isore
o Risk Ifactors Ifor Idevelopment
▪ Impaired Isensory Iperception
▪ Impaired Imobility
▪ Alteration Iin ILOC
▪ Shear
▪ Friction
▪ Moisture
o Staging
▪ 1: Iintact Iskin Iwith Inonblanchable Iredness
▪ 2: Ipartial-thickness Iskin Iloss Iinvolving Iepidermis, Idermis, Ior Iboth
▪ 3: Ifull-thickness Itissue Iloss Iwith Ivisible Ifat
▪ 4: Ifull-thickness Itissue Iloss Iwith Iexposed Ibone, Imuscle, Ior Itendon
▪ Unstageable/unclassified: Ifull-thickness Ior Itissue Iloss-
IdepthIunknown. ICompletely Icovered Iby Islough Iand/or
Ieschar.
▪ Suspected Ideep Itissue Iinjury: Idepth Iunknown; Ipurple Ior Imaroon
localized Iarea Iof Idiscolored Iintact Iskin Ior Iblood-filled Iblister Idue Ito
Idamage Iof Iunderlying Isoft Itissue Ifrom Ipressure Iand/or Ishear. IMay
IbeIpainful, Ifirm, Imushy, Iboggy, Iwarmer/cooler.
o Process Iof Iwound Ihealing
▪ Primary Iintention: Ii.e. Isurgical Iincision Iwith Ilittle Itissue Iloss; Ilow Irisk
IofIinfection, Iedges Iare Iapproximated Ior Iclosed, Ihealing Ioccurs Iquickly
Iwith Iminimal Iscar Iformation
▪ Secondary Iintention: Ii.e. Ipressure Iulcer; Iwound Iwith Iloss Iof Itissue, Ileft
open Iuntil Ifilled Iwith Iscar Itissue; Itakes Ilonger Ito Iheal; Igreater IchanceIof
Iinfection
▪ Stage I3 Iis Iresolved Ior Iclosed Ibut Inever Ihealed
▪ Complications
, • Hemorrhage I(hematoma): Ilocalized Icollection Iof
IbloodIunderneath Ithe Itissue
• Infection
• Dehiscence: Ithe Ipartial Ior Itotal Iseparation Iof Iwound Ilayers;
Ipatient Iat Irisk Ifor Ipoor Iwound Ihealing Iis Iat Irisk Ifor Idehiscence
• Evisceration: IProtrusion Iof Iorgans Ifrom Iwound; ITHIS IIS IAN
EMERGENCY, I IMMEDIATELY IPLACE IDAMP
ISTERILEIGAUZE IOVER ISITE IAND ICONTACT
ISURGICAL ITEAM.
o Prevention/ INursing Iinterventions
▪ No Iadditional Ireimbursement
▪ Good Inutrition
▪ Mechanical Iloading Iand Isupport Idevices
• Repositioning Iproperly Iand Ifrequently
o At Ileast Ievery I2 Ihrs
o 30 Idegree Ilateral Iposition
• Use Iof Itherapeutic Isurfaces
▪ Skin Icare Iand Imanagement Iof Iincontinence
• Keep Iskin Iclean Iand Idry
▪ Pain Icontrol
▪ Education
o Factors Iinfluencing Ipressure Iulcer Iformation Iand Iwound Ihealing
▪ Nutrition
▪ Tissue Iperfusion
▪ Infection
▪ Age
▪ Psychosocial Iimpact Iof Iwounds
o Important Inutrients Iand Ilab Ivalues
▪ Vitamins IAI& IC
▪ Calories: I1500 Ikcal/day
▪ Proteins
o Braden Iscale
▪ 6 Isubscales
• Sensory Iperception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction/shear
▪ Higher Iscore I Ilower Irisk I(6 Ito I23 Ipoint Iscale)
• Goals Ifor Iskin Iintegrity
o AIgood Igoal: Ipressure Iwill Ibe Ireduced Ito Isacral Iarea, Iand Ithe Iwound
IwillIs how Imovement Itoward Ihealing Iin I1 Iweek
• Wounds
o Wash Iwounds Iwith Inormal Isaline Ibefore Iculturing
o Important Ito Iidentify Ithe Isupport Isurface Ithat Iwould Ibe Iappropriate
ItoIdecrease Ipressure Ion Ipatient Iskin
