Nuft - 204: (Exam 2) Skin Integrity & Wound Care Questions

ischemia {Ans: lack of blood flow}tissue ischemia {Ans: death of skin bc lack of blood flow}necrosis {Ans: tissue death}slough {Ans: to shed dead tissue}stage IV pressure ulcer {Ans: full-thickness tissue loss with *exposed bone, tendon, or muscle*}primary intention {Ans: *edges are approximated* (when the seam is closed) usually sutured makes a fine scar}hematoma {Ans: a solid swelling of clotted blood within the tissues.}blanching {Ans: skin goes pale when pressed then goes back to pink when released (think nails)}epidermis {Ans: top layer of skin}hemostasis {Ans: *stopping / controlling blood flow*; put head lower than hips or elevate legs}frank blood {Ans: obvious blood}wound healing interventions {Ans: reposition pt redistribute pressure (w airbed) clean wound apply dressing change diet}nursing diagnoses associated with impaired skin integrity and wounds: {Ans: Risk for infection Imbalanced nutrition: less than body requirements Acute or chronic pain Impaired physical mobility Impaired skin integrity Risk for impaired skin integrity *Ineffective peripheral tissue perfusion* Impaired tissue integrity}tunneling or sinus tract {Ans: *a narrow opening or passageway underneath the skin* that can extend in any direction through soft tissue and results in dead space with potential for abscess