CCRN - Integumentary Latest 2024/2025 Updated Questions and Answers Guaranteed 100% Success.

IV Infiltration: Management - Prevention Early identification Stop the infusion Elevate warm or cool compress Monitor the site Unstageable pressure injury - Full-thickness tissue loss of unknown depth. The base of the wound is completely obscured by slough and eschar. Pressure Injury: Stage 3 - Full thickness skin loss Subcutaneous fat in wound bed No bone, tendon or muscle exposed The Skin - The largest organ system Comprises 10-15% of body weight receives 1/3 of circulating blood volume Primary functions: protective barrier, water balance, body temperature control. Pressure Injury - A localized injury to the skin that usually occurs over a bony prominence due to pressure and/or shear. Common areas are sacrum, and in young children the occiput of the head. Pressure Injury: Risk Factors - Pressure intensity and duration Shearing force ImmobilityExcessive moisture (incontinence) Inadequate nutrition Devices Skin failure (hypo perfusion) Shearing force - The pressure that's exerted on the skin when the surface layer adheres to the bedding but the deeper skin moves in the direction of the body. Skin Failure - Hypoperfusion of the skin due to shunting of blood to other vital organs. It is associated with hemodynamic changes, impaired thermoregulatory control, and metabolic complications. Pressure Injury: Stage 1 - Non-blanchable erythema Pressure Injury: Stage 2 - Partial-thickness injury Partial loss of dermis red/pink wound bed Pressure Injury: Stage 4 - Full-thickness tissue loss Bone, tendon or muscle exposed Slough or eschar in wound bed Tunnelling or undermining Pressure Injury prevention - Thorough skin and skin assessment on admission and every shift. Keep skin clean and dry Adequate nutrition Preventative dressings Pressure relief Pressure relief - Reposition frequentlyAvoid wrinkles Consider mattress surface Rotate medical devices IV Infiltration - The leaking of IV fluid into the tissue surrounding the vein. This occurs when IV fluids continue to be delivered even though the tip of the catheter is no longer in the vessel or is blocked. IV Infiltration: Signs and Symptoms - Swelling and discomfort Burning Tightness Cool skin Blanching Extravasation - Leaking of vesicant drug into the tissue. Can cause delayed healing, tissue damage and necrosis, and need for amputation. Haluronidase - Medication given after extravasation due to it's ability to increase the permeability of surrounding Deep tissue injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. tissue to promote absorption of the extravasated medication.