Blanchable - Study guides, Class notes & Summaries

Ischemic lesions of the skin and tissues caused by unrelieved pressure that interferes with blood and lymph flow - correct answer pressure ulcers dead tissue - correct answer necrosis A nurse identifies that a client has a pressure ulcer on the sacrum. Which assessment finding indicates that this is a stage III pressure ulcer? A. Non-blanchable erythema of intact skin B. Damage identifies to muscle and bone C. Skin loss to the dermis D. Necrosis of subcutaneous tissue - correct answe...

Wound Stages Answer Stage 1: - intact skin with non-blanchable redness of a localized area usually over a bony prominence. -Area may be painful, firm, soft, warmer or cooler as composed to adjacent tissue. Stage 2: -Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough - may also be present as an intact or open/ ruptured serum filled blister Stage 3: - full-thickness loss and subcutaneous fat may be visible but bone, tendon o...

tissue integrity -:- the ability of body tissues to regenerate and/or repair to maintain normal physiological processes interventions to maintain tissue integrity -:- reposition turning adequate nutrition skin assessments blanching test -:- A test of the rate of capillary refill; blanching means to cause to become pale by applying digital pressure. Non-blanchable -:- skins stay very red even with finger pressure; indicates severe skin injury Stage 1 pressure ulcer -:- intact sk...

When do you asses skin? - On admission, and on every shift. Asses ALL skin Stage 1 Pressure Ulcer - intact skin with nonblanchable redness Stage 2 Pressure Ulcer - Partial Thickness loss with serous drainage Stage 3 Pressure Ulcer - Open lesion with subcutaneous tissue exposed Stage 4 Pressure Ulcer - Full thickness tissue loss with exposed muscle and bone necrotic tissue - dead tissue Braden Scale - A tool for predicting pressure ulcer risk Severe Risk for pressure ulcer on Braden Scale ...

topic 4 objectives - ANSWER1. Examine the factors that place clients at risk for impaired skin integrity. 2. Apply the elements of a comprehensive wound assessment. 3. Utilize the planning component of the nursing process to demonstrate nurse's role and responsibilities for skin and wound care. 4. Determine nursing interventions that promote healing and the prevention of wound infections in clients with impaired skin integrity. layers of skin - ANSWERepidermis dermal-epidermal junctio...

NURS 221 - Final Exam What is wound dehiscence? A partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers What is a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers called? Dehiscence What is wound evisceration? A dehiscence that involves the protrusion of visceral organs through a wound opening What is a dehiscence that involves the protrusion of visceral organs thro...

NUR 134 EXAM 3 REVIEW QUESTIONS AND ANSWERS, GRADED A+/ VERIFIED. Abrasion - -Scarping or rubbing away of epidermis; may result in localized bleeding and later weeping of serous fluid Approximated - -to come close together, as in the edges of a wound Blanchable hyperemia - -Redness of the skin caused by dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color. Blanching - - Debridement - -Removal of foreign matter or dea...

blanchable - ️️Skin blanches with pressure. Color returns immediately with release. pressure - ️️the force (per unit area) exerted perpendicular to the skin surface.2 Pressure damages the skin and underlying tissues by (1) directly deforming and damaging tissue; (2) compressing small blood vessels hindering blood flow and nutrient supply and (3) through ischemia-reperfusion injury. When pressure is redistributed over a greater surface area, the pressure is less intense in any one ar...

papule : Solid, thickened elevated, round < 1cm in size Bulla : Blister; Superficial fluid-filled easily ruptures Nodule : Solid, usually harder in texture, deeper in the dermis Petechiae : Tiny purple/red 1-3 mm in size Keloid : Hypertrophic skin (scar) Senile angioma 2 | P a g e : Associated with "old" raised red dots Purpura : Red-purple skin lesion due to blood in tissues from breaks in BVs Patch : Maybe darker in color >2cm in size Wheal : Raised red skin lesion d...

Layers of skin epidermis Dermal-epidermal junction Dermis Subcutaneous layer Pressure injuries pathogenesis pressure intensity (tissue ischemia, blanching), pressure duration, tissue tolerance Pressure injuries risk factors impaired sensory perception, impaired mobility, alteration in loc, shear, friction, moisture Inability to perceive pressure, incontinence/moisture, decreased activity level, inability to reposition, poor nutritional intake, friction and shear Stage 1 pressure injury non-b...