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Summary NR 224 EXAM 2 STUDY GUIDE / NR224 EXAM 2 STUDY GUIDE: (LATEST 2022/2023) ,CHAMBERLAIN COLLEGE OF NURSING $17.49   Add to cart

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Summary NR 224 EXAM 2 STUDY GUIDE / NR224 EXAM 2 STUDY GUIDE: (LATEST 2022/2023) ,CHAMBERLAIN COLLEGE OF NURSING

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NR 224 EXAM 2 STUDY GUIDE / NR224 EXAM 2 STUDY GUIDE: (LATEST 2022/2023) ,CHAMBERLAIN COLLEGE OF NURSING

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  • April 6, 2022
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  • 2022/2023
  • Summary
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NR i224 iEXAM i2
CHPT i48 iSKIN iINTEGRITY iAND iWOUND iCARE

Pressure i ulcers i ilocalized i injury i on i bony i prominence i from i shear i (force i parallel i to
iskin) iand.or ifriction(dragged), imoisture

Ischemia
Blanching i-> ired itones iare iabsent i(not iin idark iskin
ipatients)iOlder iadults, idecreased iconsciousness i @ ihigh irisk

Urine i imaceration i & i skin i breakdown
Use iincontinence icleanser, idry iskin i, imoisture ibarrier
iointmenticontusion i: iclose iwound

laceration i: ijaggediirregular iedges

serous i: iwatery i, iclear
iserasangious i: iwatery, ired

ibloodifrank i: ifresh iblood

purelent i:iinfection i, ithick i, iWBC, ibacteria, itissue idebri


Skeleton i balance isuspension itraction i i shift i weight i while iimmobile,iB ucts
itraction i irestriction iof i movement i (hip ifracture)

Halo i brace ican i ambulate i with i halo i brace

Nutrition
iObservation iofiskin




Ulcers i(upiwalking, iposition ichanging)
Lifting
Clean iskin/continence icare
Elevate ithe
iheelsiRisk

iassessment

Support isurfacesifor ievenidistributions

Stage i1: inonblanchable iredness, iintact iskin i(don’t imassage)

Stage iII: iPartial ithickness i, iskin iloss i(epidermis i& idermis), iblister, iw/o
islough,ia brasion i(ex: ishallow iopen ireddish iw/o islough i(scab ilike) ion iheel iof

ifoot)




Stage iIII: ifull ithickness itissue iloss iwith ifat, islough imay ibe ipresent, idrainage
iand iinfection imay ibe ipresent i, ipurulent idischarge i(thick imilky), ifull ihad ito itoe




Stage iIV: ifull ithickness itissue iwith iexposed ibone, imuscle, ior itendon i,
iescarei( black), iHEAL iBY iSCAR iFORMATION i!

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