Multidimensional Care 1 Exam 3
Functions of the skin - ANSprotects from invasion of pathogens
thermoregulator
fluid and electrolyte balance
perception of pain
provides comfort
Classifications of wound contamination - ANSclean
clean-contaminated
contaminated
infected
Clean wound - ANSminimal inflammation
Clean-contaminated wound - ANSincreased risk for infection
Contaminated wound - ANShigh-risk for infections
Infected wound - ANSbacteria count is >100K
Classifications of wound depth - ANSsuperficial
partial thickness
full-thickness
penetrating
Superficial wound - ANSdamage to epidermis
Partial thickness wound - ANSdamage to epidermis and some dermis
Full-thickness wound - ANSreaches the subcutaneous and could pass
Penetrating wound - ANSinvolves internal organs
Phases of wound healing - ANShemostasis
inflammatory phase
proliferative phase
maturation phase
Hemostasis of wound healing - ANSblood clotting
Inflammatory phase of wound healing - ANScleaning
Proliferative phase of wound healing - ANSgranulation
,Maturation phase of wound healing - ANSscar
Types of wound healing - ANSregenerative/epithelial
first intention
second intention
third intention
Regenerative/Epithelial healing - ANSwhen only the epidermis and part of the dermis are
lost; no scar forms
First intention wound healing - ANSwound edges can connect
Second intention wound healing - ANSwound edges cannot connect and need help to heal
Third intention wound healing - ANSdelayed healing that later can be closed
Serous wound drainage - ANSclear, watery, typical clean wounds
Sanguineous wound drainage - ANSbloody
Serosanguineous wound drainage - ANSbloody and serous
Purulent wound drainage - ANSpus
Purosanguineous wound drainage - ANSbloody pus
Dehiscence - ANSseparation
Evisceration - ANStotal separation
Fistula - ANSabnormal connection between two cavities
Fungal infection culture - ANSobtained by scraping scales from skin lesions into a clean
container
specimen may be treated with potassium hydroxide and examined microscopically to
determine the presence of branched hyphae
Bacterial infection culture - ANSspecimen taken from the drainage of the lesion and placed
on a bacterial culture medium
Viral infection culture - ANSherpes lesion vesicle fluid is obtained with a cotton swab and
then placed on a tzanck smear
Punch biopsy - ANS2-6 cm plug of tissue is removed
Shave biopsy - ANSremoval of a raised lesion on the skin surface
Excisional biopsy - ANSobtained with a scalpel and have a scar similar to a surgical wound
, Skin biopsy after-care - ANSkeep dressing dry and intact for at least *eight* hours
clean site daily
antibiotic cream may be prescribed to reduce risk of infection
report any redness of drainage
if sutures are used, they are usually removed after 7-10 days
Wood's light exam - ANSUV light used to expose skin infections
Diascopy - ANSpainless technique used to eliminate erythema to reveal the shape of a skin
lesion
Pressure injuries - ANSloss of tissue integrity caused by compression of skin between a
bony prominence and an external surface
pressure results in decreased tissue perfusion, hypoxemia, tissue ischemia and cellular
death
Assessment to prevent a pressure injury - ANSmobility status
impaired sensation
impaired communication
friction and shear; keep bed at *30 degrees* or below
moisture leads to maceration (softening)
impaired nutritional status especially protein malnutrition
past-history of pressure injuries
Braden Risk Assessment Scale - ANSsensory perception
moisture
activity
mobility
nutrition
friction and shear
Norton Pressure Ulcer Scale - ANSphysical condition
mental condition
activity
mobility
incontinence
Positioning interventions to prevent development of pressure injury - ANSpad hard surfaces
with pressure redistribution properties
do not elevate head of bed greater than 30 degrees
suspend heels off the bed surface
Nutrition interventions to prevent development of pressure injury - ANSencourage protein
intake at each meal
serve protein shakes between meals
Functions of the skin - ANSprotects from invasion of pathogens
thermoregulator
fluid and electrolyte balance
perception of pain
provides comfort
Classifications of wound contamination - ANSclean
clean-contaminated
contaminated
infected
Clean wound - ANSminimal inflammation
Clean-contaminated wound - ANSincreased risk for infection
Contaminated wound - ANShigh-risk for infections
Infected wound - ANSbacteria count is >100K
Classifications of wound depth - ANSsuperficial
partial thickness
full-thickness
penetrating
Superficial wound - ANSdamage to epidermis
Partial thickness wound - ANSdamage to epidermis and some dermis
Full-thickness wound - ANSreaches the subcutaneous and could pass
Penetrating wound - ANSinvolves internal organs
Phases of wound healing - ANShemostasis
inflammatory phase
proliferative phase
maturation phase
Hemostasis of wound healing - ANSblood clotting
Inflammatory phase of wound healing - ANScleaning
Proliferative phase of wound healing - ANSgranulation
,Maturation phase of wound healing - ANSscar
Types of wound healing - ANSregenerative/epithelial
first intention
second intention
third intention
Regenerative/Epithelial healing - ANSwhen only the epidermis and part of the dermis are
lost; no scar forms
First intention wound healing - ANSwound edges can connect
Second intention wound healing - ANSwound edges cannot connect and need help to heal
Third intention wound healing - ANSdelayed healing that later can be closed
Serous wound drainage - ANSclear, watery, typical clean wounds
Sanguineous wound drainage - ANSbloody
Serosanguineous wound drainage - ANSbloody and serous
Purulent wound drainage - ANSpus
Purosanguineous wound drainage - ANSbloody pus
Dehiscence - ANSseparation
Evisceration - ANStotal separation
Fistula - ANSabnormal connection between two cavities
Fungal infection culture - ANSobtained by scraping scales from skin lesions into a clean
container
specimen may be treated with potassium hydroxide and examined microscopically to
determine the presence of branched hyphae
Bacterial infection culture - ANSspecimen taken from the drainage of the lesion and placed
on a bacterial culture medium
Viral infection culture - ANSherpes lesion vesicle fluid is obtained with a cotton swab and
then placed on a tzanck smear
Punch biopsy - ANS2-6 cm plug of tissue is removed
Shave biopsy - ANSremoval of a raised lesion on the skin surface
Excisional biopsy - ANSobtained with a scalpel and have a scar similar to a surgical wound
, Skin biopsy after-care - ANSkeep dressing dry and intact for at least *eight* hours
clean site daily
antibiotic cream may be prescribed to reduce risk of infection
report any redness of drainage
if sutures are used, they are usually removed after 7-10 days
Wood's light exam - ANSUV light used to expose skin infections
Diascopy - ANSpainless technique used to eliminate erythema to reveal the shape of a skin
lesion
Pressure injuries - ANSloss of tissue integrity caused by compression of skin between a
bony prominence and an external surface
pressure results in decreased tissue perfusion, hypoxemia, tissue ischemia and cellular
death
Assessment to prevent a pressure injury - ANSmobility status
impaired sensation
impaired communication
friction and shear; keep bed at *30 degrees* or below
moisture leads to maceration (softening)
impaired nutritional status especially protein malnutrition
past-history of pressure injuries
Braden Risk Assessment Scale - ANSsensory perception
moisture
activity
mobility
nutrition
friction and shear
Norton Pressure Ulcer Scale - ANSphysical condition
mental condition
activity
mobility
incontinence
Positioning interventions to prevent development of pressure injury - ANSpad hard surfaces
with pressure redistribution properties
do not elevate head of bed greater than 30 degrees
suspend heels off the bed surface
Nutrition interventions to prevent development of pressure injury - ANSencourage protein
intake at each meal
serve protein shakes between meals
