Wounds and Skin

d

A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the client's chance of skin breakdown? a) Keep the client in a semi-Fowler's or high-Fowler's position. b) Ensure the client is adequately hydrated. c) Massage or stimulate the client's skin surfaces daily. d) Reposition the client on a regular basis.

wound

A disruption in the normal integrity of the skin

a

A full-thickness burn develops a leathery covering called a(an): a) eschar. b) static. c) abrasion. d) erythema.

d

A home care nurse is visiting a client as a part of a regular visit. The client's daughter age 4 years falls while playing and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress to the child's knee based on the understanding that cold achieves which effect? a) Resolution of inflammation b) Increased blood flow c) Relief of muscle stiffness d) Help in controlling swelling

B

A large wound with considerable tissue loss allowed to heal naturally by formation of granulation tissue would be classified as which of the following categories of wound healing? a. Primary intention b. Secondary intention c. Tertiary intention d. None of the above

a

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? a) white blood cells, debris, bacteria b) clear, watery blood c) mixture of serum and red blood cells d) large numbers of red blood cells

a

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: a) primary intention. b) secondary intention c) tertiary intention d) dehiscence

b

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer? a) 35-year-old client who was admitted after a motor vehicle accident and has bilateral casts b) 65-year-old incontinent client with a hip fracture on bed rest c) 45-year-old client who has cancer, is receiving chemotherapy, and being admitted with leukopenia d) 70-year-old client with Alzheimer's who wanders the nursing unit and refuses to sit and eat meals

A

A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention? A. Cut in the skin from a kitchen knife B. Excoriated perineal area C. Abrasion of the skin D. Pressure ulcer

b

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? a) Use clean technique to clean the wound. b) Clean the wound from the top to the bottom, and center to outside. c) Once the wound is cleaned, dry the area with an absorbent cloth. d) Clean the wound from the bottom to the top, and outside to center.

B

A patient who is being treated for self-inflicted wounds admits to the nurse that she is anorexic. Which of the following criteria would alert the healthcare worker to her nutritional risk? a. Albumin level of 3.5 mg/dL b. Total lymphocyte count of 1,500/mm3 c. Body weight decrease of 5% d. Arm muscle circumference 90% of standard

D

A patient with a pressure ulcer on his back should be treated by which of the following methods? a. A foam wedge should be used to keep body weight off his back. b. A ring cushion should be used to protect reddened areas from additional pressure. c. The amount of time the head of the bed is elevated should be increased. d. Positioning devices and techniques should be used to maintain posture and distribute weight evenly for the patient in a chair.

B

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. It would be categorized as which of the following stages? a. Stage I b. Stage II c. Stage III d. Stage IV

telfa

A special gauze that covers the incision line and allows drainage to pass through and be absorbed by the center absorbent layer

identify the causative organism of the infected wound

A wound culture may be ordered to:

pressure ulcer

A(n) _____________ is a wound with a localized area of tissue necrosis.

Decreased rate of epidermal growth, Flattening of dermal-epidermal junction, Decreased melanocytes, Xerosis, Decreased dermal blood flow, Decreased number of sweat and sebaceous glands, Thinner dermis and collagen thinning

Age related Changes that affect the skin

a

An 80-year-old woman tells the nurse that she just itches all the time and her skin seems very dry. How do these symptoms relate to aging skin? A. activity of the glands in the skin lessens B. the symptoms are indicators of a disease C. skin gland activity increases, leading to acne D. the symptoms are unrelated to aging skin

fistula

An abnormal passage from an internal organ to the skin or from one internal organ to another is known as a(n) _____________

circular turn

Anchoring a bandage by wrapping it around the body part with complete overlapping of the previous bandage turn is the _____________ method of bandage wrapping.

transparent dressings

Applied directly over a small wound or tube, these dressings are occlusive, decreasing the possibility of contamination while allowing visualization of the wound

A

At what age is peak bone density achieved in women? A. Age 20 B. Age 18 C. It depends on factors like nutrition and activity levels. D. age 40

scar

Avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

gauze dressings

Commonly used to cover wounds; they come in various sizes and are commercially packaged as single units or in packs.

exudate

Composed of fluid and cells that escape from the blood vessels and are deposited in or on tissue surfaces

Constricts peripheral blood vessels, Reduces muscle spasms, Promotes comfort

Effects of Applying Cold

Dilates peripheral blood vessels, Increases tissue metabolism and capillary permeability, Reduces blood viscosity and muscle tension, relieves pain

Effects of Applying Heat

Ischemia, Reactive hyperemia, Vasodilation

Etiology of Pressure Ulcers

Method and duration of application, Degree of heat and cold applied, Patient's age and physical condition, Amount of body surface covered by the application

Factors Affecting the Response to Hot and Cold Treatments

C

Full thickness skin loss involving damage or necrosis of subcutaneous tissue occurs in: A. Stage I B. Stage II C. Stage III D. Stage IV

Protection, Body temperature regulation, Psychosocial, Sensation, Vitamin D production, Immunological, Absorption, Elimination

Functions of the Skin

neutrophils, polymorphonuclear

In the inflammatory cellular phase of a wound, _____________ or _____________ cells arrive first to ingest bacteria and cellular debris.

Repositioning, Mobility, Air mattress, Adequate nutrition and hydration, Regular toileting routine

Interventions to prevent Pressure Sores

24-48 hours

It is customary for the surgeon or other advanced practice professional to perform the first dressing change on a surgical wound, usually within ___________ after surgery

primary

Majority of intentional wounds heal by _________ intention

hemorrhage

May occur from a slipped suture, a dislodged clot from stress at the suture line, infection, or the erosion of a blood vessel by a foreign body (such as a drain)

Skin Cancer

Most common type of cancer

eschar

Necrotic tissue

granulation

New tissue found in a wound that is highly vascular, bleeds easily, and is formed in the proliferative phase is known as _____________ tissue.

granulation tissue

New tissue, pink-red in color, composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

Protein, Vitamin C, Vitamin A, zinc, Chronic wound supplements

Nutrition for Wound Healing

basal cell, squamous cell carcinoma

Older adults highly vulnerable to __________ _________ and __________ ________ ______________ due to the cumulative effects of sun exposure

Hemostasis, Inflammatory, Proliferation, Final stage of healing

Phases of Wound Healing

BJAFHIKGDCE

Place the following steps to collecting a wound culture in the order in which they should be performed. a. Using aseptic technique, don sterile gloves and clean wound. Remove sterile gloves. b. Explain the procedure to patient; gather equipment; perform hand hygiene. c. Apply clean dressing to wound. d. Perform hand hygiene. Remove all equipment and make patient comfortable. e. Remove gloves from inside out, and discard them in plastic waste bag. Perform hand hygiene. f. Twist cap to loosen swab in Culturette tube, or open separate swab and remove cap from culture tube, keeping inside uncontaminated. Don clean glove or new sterile glove, if necessary. g. Label specimen container appropriately, attach laboratory requisition to tube with a rubber band or place tube in plastic bag with requisition attached; send to lab within 20 minutes. h. Carefully insert swab into wound and roll gently. Use another swab if collecting specimen from another site. i. Place swab in Culturette tube, being careful not to touch outside of container. Twist cap to secure; if using Culturette tube, crush ampule of medium at bottom of tube. j. Don clean disposable gloves. Remove dressing and assess wound and drainage. k. Record collection of specimen, appearance of wound, and description of drainage in chart.

ABDs, surgipads

Placed over the smaller gauze to absorb drainage and protect the wound from contamination or injury

sof-wick

Precut halfway to fit around drains or tubes

Staging, Color, type, Drainage, Tunnelling, Epithelialization/granulation, Peri-wound condition

Pressure Ulcer Evaluation

tissue ischemia

Pressure ulcers are caused by pressure for sufficient period of time to cause ___________ __________

Superficial, No scarring, small, edges come together

Primary intention

Pain, Anxiety, Fear, Loss of function, Change in body image

Psychological Effects of Wounds

prevent accumulation of fluid & air

Purpose of Drainage Systems

Provide physical, psychological, and aesthetic comfort, Remove necrotic tissue, Prevent, eliminate, or control infection, Absorb drainage, Maintain a moist wound environment, Protect wound from further injury, Protect skin surrounding wound

Purposes of Wound Dressings

puss, generally yellow, can be any color

Purulent drainage

Exposure to UV rays Adverse medication effects Diseases Personal hygiene habits Smoking or alcohol consumption Immobility/limited activity Heredity

Risk Factors that Affect Skin

Sensory impairment, Immobility, Urinary & Bowel incontinence or other exposure to moisture, Inadequate nutritional intake, Diminished sensation, Friction and shearing

Risk factors for pressure sores

red, bleeding

Sanguineous drainage

Edges of the wound are not together, and can't be brought together, Pathogens have migrated into the wound, Granulation tissue fills in the edges that don't go together, re-epithelialization over top, Scarring

Secondary intention

into not through dermis

Secondary intention Partial thickness:

through dermis

Secondary intention full thickness:

some blood, some serous drainage

Serosanguineous drainage

plasma-like, yellow/clear

Serous drainage

Evisceration

Something from the inside comes out

bandages

Strips of cloth, gauze, or elasticized material used to wrap a body part

exudate

Swelling and pain that occur from an incision are caused by an accumulation of _____________

Age, Circulation and oxygenation, Nutritional status, Wound condition, Health status, Immunosuppression, Medication

Systemic Factors Affecting Wound Healing

true

T or F: A moist wound surface enhances the cellular migration necessary for tissue repair and healing.

false

T or F: Dehiscence is the softening of tissue due to excessive moisture

true

T or F: Medicare will not pay hospitals for decubitus ulcers caused by the hospital

true

T or F: Montgomery straps allow the nurse to change a dressing without the use of tape

very infrequent, Intentionally left open due to infection, Closed later

Tertiary intention

b

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? a) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." b) "Your wound will heal slowly as granulation tissue forms and fills the wound." c) "As soon as the infection clears, your surgeon will staple the wound closed." d) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."

wound is clean, protected, uncontaminated, without trauma or pain

The expected outcome to achieve when cleaning a wound and applying a dry, sterile dressing is:

b

The nurse would recognize which client as being particularly susceptible to impaired wound healing? a) a client whose breast reconstruction surgery required numerous incisions b) an obese woman with a history of type 1 diabetes c) A client who is n.p.o. (nothing by mouth) following bowel surgery d) a man with a sedentary lifestyle and a long history of cigarette smoking

dehiscence

The partial or total disruption of wound layers

evisceration

The protrusion of viscera through the incisional area

transparent dressings

The type of dressing often used over intravenous sites, subclavian catheter insertion sites, and healing wounds

jp drain

They are typically used with breast and abdominal surgery

binders

They may be made of cloth (flannel or muslin) or an elasticized material that fastens together with Velcro.

saline-moistened dressing

This type of dressing promotes moist wound healing and protects the wound from contamination and trauma

Surgical, Enzymatic/Chemical, Mechanical, Autolytic

Types of Debridement of Eschar/Slough

Sterile, clean, Cover, Debride, Absorb

Types of Wound Dressings

Serous, Sanguineous, Serosanguineous, Purulent

Types of Wound drainage

Intentional or unintentional, Open or closed, Acute or chronic, Partial thickness, full thickness , complex

Types of Wounds

open, closed

Types of drains

Depth unknown, Covered in eschar/slough

Un-stageable/unclassified pressure ulcer

dressing

Used as a protective cover over a wound

telfa

Used to prevent outer dressings from adhering to the wound and causing further injury when removed

Granulation tissue

What is the beefy red tissue that forms during healing?

a

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a) Off-load pressure from the heel. b) Contact the surgeon for deibridement. c) Place a TED hose on the client's leg. d) Using sterile technique, debride the wound.

B

When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional vomiting and is not keeping fluids down well, which of the following would you be most concerned about? A. Post surgical hemorrhage and anemia B. Wound dehiscence and evisceration C. Impaired skin integrity and decubitus ulcers D. Loss of motility and paralytic illeus

A

When cleaning a wound, the nurse should adhere to which of the following protocols? a. The wound should be cleaned with each dressing change. b. Friction should be used with cleaning materials to loosen dead cells. c. Povidone-iodine or hydrogen peroxide should be used to fight infection in the wound. d. Irrigating devices should not be used on wounds because they damage the cells needed for healing.

A

When working with an older person, you would keep in mind that the older person is most likely to experience which of following changes with aging? A. thinning of the epidermis B. thickening of the epidermis C. oiliness of the skin D. increased elasticity of the skin

Pressure ulcer, scrape

When would you use clean technique?

Any surgical/intentional wound

When would you use sterile technique when caring for a wound?

Sterile 0.9% sodium chloride solution

Which antiseptic cleaning agent is usually used to clean a wound?

BCF

Which of the actions would a nurse be expected to perform when using cold therapy during wound care? (Select all that apply.) a. Apply an ice bag for 1 hour and then remove it for about an hour before reapplying it. b. Place a hypothermia blanket on the bed and cover it with a sheet so the patient's skin does not come in direct contact with the cold blanket. c. Monitor the patient's rectal temperature every 15 minutes and all vital signs every 30 minutes when using a hypothermia blanket. d. Change cold compresses frequently, continuing the application for 1 hour, and repeating the application every 2 to 3 hours as ordered. e. Avoid wringing out cold compresses to prevent diminishing the effect of the cold. f. In a home setting, use a bag of frozen vegetables (such as peas), if desired, as a substitute for a cold compress.

BCD

Which of the following are characteristics of Y (yellow) wounds? (Select all that apply.) a. They reflect the color of normal granulation tissue. b. They are characterized by oozing from the tissue covering the wound. c. They should be cleansed by irrigating the wound and using wet-to-moist dressings and absorptive dressings. d. The nurse should consult with the physician about using a topical antimicrobial medication to decrease the growth of bacteria. e. They are covered with thick eschar. f. They are usually treated by using sharp, mechanical, or chemical débridement.

ADE

Which of the following are effects of the application of heat in wound care? (Select all that apply.) a. The application of heat dilates peripheral blood vessels. b. The application of heat decreases tissue metabolism. c. The application of heat increases blood viscosity and capillary permeability. d. The application of heat reduces muscle tension and helps relieve pain. e. Extensive, prolonged heat increases cardiac output and pulse rate. f. Extensive, prolonged heat increases blood pressure.

C

Which of the following drains provide sinus tract and would be used after incision and drainage of an abscess, in abdominal surgery? a. T-tube b. Jackson-Pratt c. Penrose d. Hemovac

ADE

Which of the following generally occur during normal wound healing? (Select all that apply.) a. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. b. It takes approximately 2 weeks for the edges of the wound to appear normal and heal together. c. Increased swelling and drainage may occur during the first 5 days of the wound. d. The wound should not feel hot upon palpation. e. The inflammatory response results in the formation of exudate in the wound. f. Incisional pain during wound healing is usually most severe for the first 3 to 5 days and then progressively diminishes.

ABC

Which of the following interventions might a nurse be expected to perform when providing competent care for a patient with a draining wound? (Select all that apply.) a. Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. b. Change the dressing midway between meals. c. Apply a protective ointment or paste, if appropriate, to cleaned skin surrounding the draining wound. d. Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. e. Apply an absorbent dressing material as the first layer of the dressing. f. Apply a nonabsorbent material over the first layer of absorbent material.

D

Which of the following is an effect of applying heat to a body part? a. Constriction of peripheral blood vessels b. Reduced blood flow to tissues c. Increased venous congestion d. Increased supply of oxygen and nutrients to the area

D

Which of the following patients would be at greatest risk for developing a pressure ulcer? a. A newborn b. A patient with cardiovascular disease c. An older patient with arthritis d. A critical care patient

A

Which of the following patients would most likely develop a pressure ulcer from shearing forces? a. A patient sitting in a chair who slides down b. A patient who lifts himself up on his elbows c. A patient who lies on wrinkled sheets d. A patient who must remain on his back for long periods of time

C

Which of the following recommendations for wound dressing is accurate? a. Use wet-to-dry dressings continuously. b. Keep the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. c. Select a dressing that absorbs exudate, if it is present, but still maintains a moist environment. d. Pack wound cavities tightly with dressing material.

AEF

Which of the following statements accurately describe a factor in the development of a pressure ulcer? (Select all that apply.) a. Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue. b. Most pressure ulcers occur over the trochanter and calcaneus. c. Generally, a pressure ulcer will not appear within the first 2 days in a person who has not moved for an extended period of time. d. The major predisposing factor for a pressure ulcer is internal pressure applied over an area, which results in occluded blood capillaries and poor circulation to the tissues. e. The skin can tolerate considerable pressure without cell death, but for short periods only. f. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation.

BCF

Which of the following statements accurately describe the complications that may occur during wound healing? (Select all that apply.) a. Symptoms of wound infection are usually apparent within 1 to 2 weeks after the injury or surgery. b. Dehiscence is present when there is a partial or total disruption of wound layers. c. During evisceration, the viscera protrude through the incisional area. d. Patients who are thin are at greater risk for these complications owing to a thinner layer of tissue cells. e. An increase in the flow of serosanguineous fluid from the wound between postoperative days 4 and 5 is a sign of an impending evisceration. f. Postoperative fistula formation is most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site.

ABE

Which of the following statements accurately describe the effect of various factors on wound healing? (Select all that apply.) a. Children heal more rapidly than older adults. b. Adequate blood flow is essential for wound healing. c. People who are thin may heal more slowly due to the small amounts of subcutaneous and tissue fat in their bodies. d. Vitamins B and D are essential for reepithelialization and collagen synthesis. e. People who are taking corticosteroid drugs are at high risk for delayed healing. f. Radiation increases bone marrow function, resulting in increased leukocytes and a decreased risk for infection.

BCE

Which of the following statements accurately describe the formation of pressure ulcers? (Select all that apply.) a. Reactive hyperemia is considered a stage I pressure ulcer. b. A stage II pressure ulcer is superficial and may present as a blister or abrasion. c. Damage to the subcutaneous tissue indicates a stage III lesion. d. A stage III pressure ulcer presents with fullthickness skin loss. e. If eschar is present, it may be difficult to stage a pressure ulcer. f. The first indication that a pressure ulcer may be developing is reddening of the skin over the area under pressure.

CDE

Which of the following statements describe the proper use of the various types of dressings? (Select all that apply.) a. A Surgipad is often used to cover an incision line directly. b. Transparent dressings are applied over ABDs to help keep the wound dry. c. Op-Site is often used over intravenous sites, subclavian catheter insertion sites, and noninfected healing wounds. d. Using appropriate aseptic techniques when changing dressings is crucial. e. Gauze dressings are commonly used to cover wounds. f. Telfa is applied to the wound to keep drainage from passing through and being absorbed by the outer layer

C

Which of the following vitamins is needed for collagen synthesis, capillary formation, and resistance to infection? a. Vitamin A b. Vitamin B c. Vitamin C d. Vitamin K

CDE

Which of the following would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? (Select all that apply.) a. Clean the wound with each dressing change using aggressive motions to remove necrotic tissue. b. Use povidone-iodine or hydrogen peroxide to irrigate and clean the ulcer. c. Use whirlpool treatments, if ordered, until the ulcer is considered clean. d. Keep the ulcer tissue moist and the surrounding skin dry. e. Select a dressing that absorbs exudate, if present, but still maintains a moist environment for healing. f. Pack wound cavities densely with dressing material to promote tissue healing.

c

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound? a) Stage IV pressure ulcer b) Stage III pressure ulcer c) Stage II pressure ulcer d) Stage I pressure ulcer

Infection, Hemorrhage, Dehiscence and evisceration, Fistula formation

Wound Complications

sanguineous wound drainage

Wound drainage that consists of large numbers of red blood cells and looks like blood

serous wound drainage

Wound drainage that is composed of the clear, serous portion of the blood and drainage from serous membranes

purulent wound drainage

Wound drainage that is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria

red wounds

Wounds in the proliferative stage of healing that are the color of granulation tissues

yellow wounds

Wounds that are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage

black wounds

Wounds that are covered with thick eschar, which is usually black but may be brown, gray, or tan

intentional wounds

Wounds that result from surgery, intravenous therapy, and lumbar punctures are commonly known as _____________

binders

Wraps designed for a specific body part

D

You are giving a back rub to an older patient at home and notice a stage II pressure ulcer. Which of the following treatments would you suggest for this patient? a. Treat the ulcer using pressure relieving devices. b. Use a wet-to-dry dressing on the wound. c. Cover the wound with a nonadherent dressing and change every 8 to 12 hours. d. Maintain a moist healing environment with a saline or occlusive dressing to promote natural healing

Frailty

a state of high vulnerability for adverse health outcomes, including disability, dependency, falls, need for long-term care, and mortality

Reactive hyperemia

bright red flush (temporary)

nasal swab

can be part of the screening process to detect potential infection with drug resistant microorganisms

inflammatory

cellular stage of wound healing

JP drain

collects wound drainage in a bulblike device that is compressed to create gentle suction

maintaining asepsis

crucial part of collecting a wound culture

Vasodilation

extra blood to area

promote tissue repair and regeneration, restore skin integrity

goals of wound care

Hemorrhage

hit wrong blood vessel when skin is open

Ischemia

lack of blood supply to tissue

Fistula

long tube-like structure that forms either between 2 organs or between an organ and the world

nasal swab

may be used to diagnose infectious respiratory tract diseases, such as influenza

melanoma

most dangerous form of skin cancer

Infection

pathogens go into opening in the skin

Final stage of healing

phase of wound healing where collagen is remodeled, begins about 3 weeks to 6 months after injury

Proliferation

phase of wound healing where new tissue fills in the wound

hemovac

placed into a vascular cavity where blood drainage is expected after surgery, such as with abdominal and orthopedic surgery

nasal swab

provides a sample for culture to aid in the diagnosis of infection and detect the carrier state for certain organisms

obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration

risk factors of dehiscence

Non-blanchable redness, heat, pain, maybe blister, Skin isn't broken, Darkly pigmented skin may not have visible blanching

stage 1 pressure ulcers

Partial thickness, Cracking, shallow breakthrough, Loss of dermis, shallow open ulcer with a red pink wound bed, without slough

stage 2 pressure ulcers

Underlying subcutaneous tissue breaks through, No muscle/bone visible, May include undermining and tunneling, depth varies

stage 3 pressure ulcers

Full thickness tissue loss with exposed bone, tendon or muscle, Exposed bone/muscle is visible or directly palpable, Slough or eschar may be present, Often includes undermining and tunneling, depth varies

stage 4 pressure ulcers

nasal swab

used to detect the presence of organisms, such as Staphylococcus aureus, which may colonize on the skin in the nose, skin folds, hairline, perineum, and navel

Hemostasis

vascular stage of wound healing

wet to dry

what is the best dressing for pressure ulcers?

xerosis

what is the name for extremely dry skin as you age?

Dehiscence

when cut gets pulled apart and left open

4-5 days postoperatively

when is Dehiscence most likely to occur?

over bony prominences

where do pressure ulcers usually occur?

remove debris, contaminants, and excess exudate

wound cleansing is performed to: