Nur 155 Exam 3 Study Guide Complete Latest 2023 Graded A+.

NUR 155 EXAM 3 STUDY GUIDE COMPLETE LATEST 2023 GRADED A+. NUR 155 EXAM 3 REVIEW: SKIN INTEGRITY AND WOUND CARE Types of cleanliness of wounds:  Clean wound- are uninfected wounds with minimal inflammation and the respiratory, GI, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds  Clean-contaminated wounds- are surgical wounds in which the respiratory, GI, genital, or urinary tract has been entered. Such wounds show no signs of contamination.  Contaminated wounds- include open, fresh, accidental wounds and surgical wounds involving a major break in the sterile technique or a large spillage from the GI tract. Show evidence of inflammation  Dirty or infected wounds- wounds containing dead tissue and wounds with evidence of clinical infection such as purulent drainage Types of wounds: - Incision- caused by a sharp instrument; open wound; deep or shallow; once the edges have been sealed together as a part of treatment or healing the incision becomes a closed wound - Contusion- caused by a blow from a blunt instrument; closed wound, skin appears ecchymosis because of the damage blood vessels. - Abrasion- caused by surface scrape, either unintentional (scraped knee) or intentional (dermal abrasions to remove pockmarks; open wound involving the skin - Puncture- caused by penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional; open wound - Laceration- tissues torn apart, often from accidents; open wound, edges are often jagged - Penetrating wound- penetration of the skin and the underlying tissues, usually unintentional (ex- from bullet or fragments); open wound Wound assessments: -very important in documenting. Braden scale consist of 6 subscales; sensory perception, moisture, activity, mobility, nutrition, and friction and shear. 23 points possible, if you score an 18 you are at risk - take photographs of wounds -measure wound depth from deepest part of the wound. -measure wound length from longest portion of the wound. Lab values associated with wounds: - WBC: worried about infection. Normal labs :4500-10,000 - Hemoglobin- carries oxygen in the blood. Normal labs: female: 12-15 male: 15-18 - Albumin- indicates nutritional status. Normal values: 3.5-5.5 g/dL - Serum protein- nutritional value of reserved protein - Wound cultures- swabbed in wound and tested. Looks for bacteria, MRSA, Staph. You want them to be negative Pressure ulcers- consist of an injury to the skin and or underlying tissue usually over a bony prominence - Due to localized ischemia, a deficiency in the blood supply to the tissue. - Skin becomes unblanchable- meaning when you press down on the redness it stays red and doesn’t turn white - This redness is due vasodilation - Incontinence is a bag factor in sacrum pressure ulcer Friction- is a force acting parallel to the skin