N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide o Scales: These are dry flakes of the skin. o Crusts: These are dried areas of pus. o Erosion: This is a partial loss of the skin. o Ulcer: This is a complete loss of the skin in a specific area. o Lichenification: This is a thickening of the skin with an exaggerated appearance. o Abscesses: These are depressions filled with pus. o Burrow: This is a small tunnel under the skin by parasites, such as scabies. o Petechiae: These are small red spots on the skin's surface caused by the hemorrhage. o Papilloma: This is a mass above the surface of the skin that looks like a nipple. How Wounds Heal Wounds can heal by primary, secondary, or tertiary intention: • Primary intention healing occurs when there is minimal tissue lost and the edges of the wound are pulled together, like by suturing. The risk of infection is typically low and scarring is minimal. • Secondary intention healing occurs with full-thickness injuries and tissue loss where the edges of the wound cannot be pulled together. Because the wound must heal by filling in with granulation tissue, the wound is open longer, making the risk of infection higher. Healing by secondary intention takes longer and may result in more scarring. Pressure ulcers and burns must usually heal by secondary intention. • Tertiary intention healing occurs when treatment is delayed and the risk of infection and scarring increases. Suppuration (formation of pus) is very likely to occur since treatment has been delayed. When a wound is infected and during the healing process, fluid and cells escape from the capillaries around the wound and create drainage or exudate. Drainage is typically described by the type of fluid that is seen: • Serous drainage is clear andwatery. • Serosanguineous drainage is a mixture of serum (sero) and blood (sanguineous). It is typically pale red andwatery. • Purulent drainage, also known as pus, is made up of dead cells and debris. Usually caused by infection, this drainage is typically thick and may be yellow, green, or tanor brown. Purulent drainage may also be foul smelling. Wound Dressings Dressings are applied to wounds to protect the wound from further injury, to protect from contamination, to provide humidity to the wound, to absorb drainage from the wound, to apply pressure to stop bleeding, to immobilize the site, to facilitate healing, and to cover up an esthetically unpleasant wound. When choosing the type of dressing to be used on a wound, the prudent nurse will be guided by the

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