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Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Ed., Taylor, Lynn & Bartlett/
Chapter 33: Skin Integrity and Wound CareAce Your Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Ed., Taylor, Lynn & Bartlett Classes and Exams with Picmonic: #1 Visual Mnemonic Study Tool for Registered Nurse (RN) Students
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Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Ed., Taylor, Lynn & Bartlett | Registered Nurse (RN) School Study Aid
Interventions for Impaired Skin Integrity
- Assessment
- Signs of Skin Breakdown
- Pain
- Redness
- Decreased Skin Turgor
- Bleeding
- Bony Prominences
- Intervention
- Reposition Q2H
- Pressure Relief
- Maintain Clean and Dry Skin
- Adequate Nutrition and Hydration
2 mins
Chronic Venous Insufficiency (Venous Stasis Ulcer) Interventions
- Frequently Elevate Legs
- Avoid Standing/Sitting for Long Periods of Time
- Elastic Compression Stockings
- Bilayer Artificial Skin
- Daflon
- Wound Dressings
- Proper Foot and Leg Care
2 mins
Wound Drainage Types and Devices
- Drainage Types
- Serous
- Serosanguineous
- Sanguineous
- Purulent
- Drainage Devices
- T-tube
- Penrose
- Jackson-Pratt (JP)
- Hemovac
- Considerations
- Record Drainage Amounts
- Check Device Function
2 mins
Postoperative Care
- Head to Toe Assessment
- Complications
- Hemorrhage
- Clotting
- Pain
- Dehiscence or Evisceration
- Respiratory Complications
- Paralytic Ileus
- Infection
2 mins
Preoperative Care
- Preop Education
- Surgical Procedure
- NPO
- Turn, Cough, Deep Breathe, Incentive Spirometer
- Lower Extremity Exercises
- Compression Stockings or SCD's
- Pain Management
- Safety
- Informed Consent
- Physical Preparation
- Preop Checklist
- Handoff to Surgery
- Universal Precautions
2 mins
Colostomy Care
- Wash with Warm Water
- Cut 1/8 inch Around Stoma
- Decreases Skin Irritation
- Empty When 1/3 to 1/2 Full
- Change 3-7 Days
- Considerations
- Avoid Odor Causing Foods
- Irrigate at Same Time
2 mins
Tracheostomy Care
- Inner Cannula Removed and Cleaned
- Clean Q8 Hours Around Stoma
- One Finger Under Ties
- Considerations
- Speak with Deflated Cuff
- Can Eat with Tube in Place
- Keep Replacement Tube Nearby
- Immediately Replace if Dislodged
- Physician Does First Tube Change
2 mins
Ileostomy Care
- Antibiotics
- Monitor Skin Breakdown
- Drains Continuously
- Fluid and Electrolyte Imbalance
- Low Fiber Diet
2 mins
Burns Assessment
- Stage and Extent of Burn
- Dyspnea
- Singed Nasal Hairs
- Pain
- Initial Decrease Urinary Output
- Paralytic Ileus
- Signs of Inadequate Hydration
- Shock
- Hypothermia
- Hyperkalemia
2 mins
Types of Wound Healing
- Types of Wounds
- Acute
- Chronic
- Healing Process
- Primary Intention
- Approximated Edges
- Secondary Intention
- Edges Not Approximated
- Tertiary Intention
- Delayed Closure due to Infection and Necrosis
2 mins
Skin Functions
- Characteristics
- Thermoregulation
- Protection
- Innate Immune Protection
- Synthesize Vitamin D
- Water and Salt Excretion
- Dilated Capillaries are a Blood Reservoir
2 mins
Skin Anatomy
- Characteristics
- Epidermis
- Keratinocytes
- Melanocytes
- Dendritic Cells
- Merkel Cells
- Dermis
- Sweat Glands
- Hair Follicles
- Sebaceous Glands
- Hypodermis
3 mins
Stages of Burn Care
- Phase / Stage 1
- Resuscitative/Emergent Phase
- Injury to Return of Capillary Permeability
- 48-72 hours
- IV Fluid Replacement
- Phase / Stage 2
- Acute Phase
- Diuresis to Near Wound Closure
- Phase / Stage 3
- Wound Closure to Return of Optimal Level
2 mins
Chest Tubes: Management and Care
- Confirm suction order
- Assessment
- Crepitus
- Kinking
- Shortness of Breath (SOB)
- Infection
- Excessive bubbling
- Quick Interventions
- If tube dislodges from patient, use petroleum gauze taped 3 ways
- If drainage system is damaged, place disconnected drainage tube in sterile water
1 min
Pressure Ulcers
- Risk Factors
- Prolonged Immobilization
- Neurologic Disease
- Decreased Level of Consciousness
- Classification
- Stage 1: Intact Skin with Non-blanchable Erythema
- Stage 2: Partial Thickness Skin Loss
- Stage 3: Full-thickness Skin Loss without Fascial Involvement
- Stage 4: Full-thickness Skin Loss with Fascial Involvement
- Management
- Wound Care
- Surgery
- Considerations
- Septicemia
- Osteomyelitis
- Prevention
3 mins
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