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NUR 155 Proctored Exam 4 2024 $13.08   Add to cart

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NUR 155 Proctored Exam 4 2024

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Laceration - Tissue torn apart often by accidents Abrasion - Surface scrape either unintentional or intentional Contusion - Blow from a blunt instrument Avulsion - A wound that occurs when tissue is separated from the body Penetrating wound - Penetration of the skin and underlying tissu...

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  • August 17, 2024
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NUR 155 Proctored Exam 4 2024

Laceration - Tissue torn apart often by accidents



Abrasion - Surface scrape either unintentional or intentional



Contusion - Blow from a blunt instrument



Avulsion - A wound that occurs when tissue is separated from the body



Penetrating wound - Penetration of the skin and underlying tissue



Skin tear - a break or rip in the outer layers of the skin; the epidermis separates from the underlying
tissues



Labs associated with wounds - WBC >

hEMOGLOBIN < (O2 TO TISSUE)

SERUM PROTEIN (CONTAIN ALBUMIN)

WOUND CULTURE: PT, PTT, INR, PLATELET.



Normal lab value - WBC 5-10

hemoglobin: male 14-18, female 12-16

Albumin: 3.5-5

PTT: 20-30 SEC

PT: 11-12.5 SEC

INR: 0.9-1.2 SEC

PLT: 150-400

,STATE THE FOUR STAGES OF PRESSURE ULCER - Stage 1: nonblanchable errythema, no
ulceration

stage 2: partial thickness, skin loss abrasion involving epidermis and dermis

stage 3: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend
down to but not through underline fascia

stage 4: full thickness skin loss with tissue necrosis with damage to muscle and bone



Braden scale - A tool for predicting pressure ulcer risk

total 23 points, < 18 at risk



Norton pressure area risk assesment - Total score 24, 15-16 considered indicators not predictors at risk



RYB- RED - regeneration phase- gentle cleansing don't apply pressure protect agranulation tissue

use non-cytotoxic wound cleanser w/o pressure

alcohol free barrier film

PROTECT-COVER



RYB- BLACK - DEBRIDE (REMOVAL OF NECROTIC MATERIAL)



RYB- YELLOW - CLEANSE



Sharp debridement - requires use of scalpel, scissors, and/or forceps to selectively remove devitalized
tissues, foreign materials or debris from a wound.



Mechanical debridement - scrubbing force or damp to damp dressings



Chemical debridement - collagenase enzymes

, Transparent film - film dressings are thin membranes made from transparent polyurethane with water
resistant adhesives. allow easy visual inspection of the wound since they are transparent. STAGE 1



impregnated nonadherent - Woven and non woven synthetic materials that are impregnated with
petroleum, saline, zinc.

PARTIAL OR FULL THICKNESS WOUNDS



Hydrocolloids - STAGE 2-4



WHAT ARE THE THREE CHARACTERISTICS FOR PRIMARY THAT SECONDARY HAS -
1.)REPAIR TIME IS LONGER

2.)SCARRING IS GREATER

3.)SUSCEPTIBILITY TO INFECTION IS GREATER



autolytic debridement - Hydrocolloid and clear absorbent acrylic dressings



Inflammatory phase of wound healing - Last 3-6 days

begins immediately after injury

maintain homeostasis

phagocytosis



proliferation phase of wound healing - Starts day 3 or 4 after inflammatory phase

lasts 21 days

granulation tissue starts and collagen



maturation phase of wound healing - Begins day 21

fibroblasts continue to synthesize collagen

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