NURS307 Chapter Notes -Wound Healing, Fibrin, Dermis
Document Summary
Impaired mobility: altered loc, shear force exerted parallel to the skin due to gravity and friction between the surface, friction, moisture, nutrition, tissue perfusion (oxygenation, pain rapid, shallow breathing and tensed muscles decrease tissue perfusion, Infection diminished appetite: age, psychosocial impact of wounds. Sensory perception ability to respond meaningfully to pressure-related discomfort. Mobility ability to change and control body position: reposition at minimum every 2 hrs, limit chair duration. Friction and shear: elevate head of bed less than 30 degrees. Suspected deep tissue injury: purple/maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue. Stage iii: full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle not exposed, slough may be present but doesn"t obscure depth of tissue loss. Stage iv: full thickness loss with exposed bone, tendon or musle.
