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:
