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wri cum hay dung

🧴 1. SKIN ASSESSMENT – DETAILED NOTES 📄 ⭐ Purpose of Skin Assessment * Identify early signs of breakdown * Detect circulation or oxygenation issues * Prevent pressure injuries * Monitor healing or worsening conditions 🧠 What You Assess (Head-to-Toe Skin Check) 🔹 1. Temperature * Warm = normal * Cool = ↓ circulation * Hot = infection/inflammation 🔹 2. Color * Pallor → anemia / ↓ oxygen * Cyanosis → poor oxygenation (BLUE = BAD) * Redness → inflammation / pressure 🔹 3. Turgor * Pinch skin (usually chest or forehead) * Normal = snaps back quickly * Tented = dehydration 🔹 4. Moisture * Dry → dehydration * Diaphoretic → fever, stress * Excess moisture → breakdown risk 🔹 5. Integrity * Intact vs open areas * Look for: * wounds * tears * ulcers 🔹 6. Capillary Refill * Press nail bed * Normal = < 2 seconds * Delayed = poor perfusion 🔹 7. Edema * Swelling = fluid buildup * Check severity (pitting scale) 🚨 PRIORITY AREAS TO CHECK * Bony prominences (sacrum, heels, elbows) * Skin folds (obese patients) * Under devices (oxygen tubing, stockings) * Areas with ↓ sensation ⚠️ HIGH-YIELD FINDINGS * Non-blanchable redness = Stage 1 pressure injury * Cool, pale skin = ↓ perfusion * Moist skin = ↑ breakdown risk 🩹 2. SKIN TRAUMA & PRESSURE ULCERS – DETAILED NOTES 📄 ⭐ What is Skin Trauma? Damage to the body’s protective barrier ⚠️ Causes of Poor Wound Healing * Malnutrition * Poor blood flow * Infection * Smoking * Medications (steroids) * Age 🧬 Wound Healing Phases 1. Inflammatory * Redness, swelling * Body sends immune cells 2. Proliferative * New tissue forms * Wound starts closing 3. Maturation * Remodeling * Scar forms 👉 Know the ORDER!! 🔥 Types of Wound Healing * Primary intention → clean, closed (sutures) * Secondary intention → open wound heals slowly * Tertiary intention → delayed closure 🚨 PRESSURE INJURIES ⭐ Causes: * Pressure * Friction * Shearing ⭐ Risk Factors: * Immobility * Incontinence * Poor nutrition * ↓ mental status 🔴 STAGES (VERY TESTED) Stage 1: * Non-blanchable redness * Skin intact Stage 2: * Partial thickness * Blister / shallow wound Stage 3: * Full thickness * Fat visible Stage 4: * Muscle or bone exposed Unstageable: * Covered with slough/eschar Deep Tissue Injury: * Purple/maroon skin 🚑 INTERVENTIONS (PRIORITY CARE) * Turn every 2 hours * Keep skin clean and dry * Use barrier creams * Promote nutrition (protein!!!) * Assess skin daily ❌ DO NOT: * Massage reddened areas ⚠️ COMPLICATIONS * Infection * Dehiscence (wound opens) * Evisceration (organs out = emergency) 🧴 3. SKIN CONDITIONS – DETAILED NOTES 📄 ⭐ COMMON CONDITIONS 🔹 Dryness / Pruritus * Dry, itchy skin * Causes: * dehydration * irritants * allergies Treatment: * Moisturizers * Antihistamines * Steroids 🔹 Urticaria (Hives) * Raised, itchy welts * Blanch with pressure Treatment: * Antihistamines * Steroids * Epinephrine (severe) 🔥 Psoriasis (VERY TESTED) * Chronic autoimmune disorder Signs: * Silvery scales * Red plaques * Common areas: * elbows * knees * scalp Treatment: * Steroids * UV therapy * Biologic drugs 🔥 Cellulitis (IMPORTANT) * Bacterial infection Signs: * Red * Warm * Swollen * Painful Treatment: * Antibiotics * Elevate extremity 🔥 Shingles (VERY TESTED) * Reactivation of chickenpox Signs: * Painful vesicles * Burning/tingling Key Point: 👉 Contagious to people who never had chickenpox 🔥 Skin Cancer Types: * Basal cell * Squamous * Melanoma (most dangerous) ⭐ ABCDE RULE: * A = asymmetry * B = border * C = color * D = diameter * E = evolving 🧠 Nursing Diagnoses: * Impaired skin integrity * Risk for infection * Pain * Disturbed body image 🛌 4

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