文档介绍：,MSN,anismsRegulationofbodytemperatureTransmitssensationsofpain,temperature, touchandpressure--VitaminDproductionandabsorption--secretessebumWoundsWhatarewounds?BreakinskinormucousmembranesWoundClassificationSuperficialDeep(bloodvessels,nerves,muscle,tendons,ligaments,bones)OpenWoundSuperficialordeepbreakinskin(abrasion,puncture,laceration)WoundClassificationClosed:bluntforce;twisting,turning,straining,bonefracture,antearAcute:traumasharpobjectorblowSurgicalincision,gunshot,venipunctureChronic:pressureulcersCausalityIntentional:surgicalincisionUnintentional:traumaticKnifeBurnPressureWoundsDamagetotissuesduetopressureFactorsImmobilityElderlySkinmoistureMalnutrition(protein)ShearingForcesFrictionRiskFactorsasoutlinedonBradenScalePressureUlcerStagesStageI:NoSkinBreakSkintemperature,consistency(firm),sensation(painoritching)PersistentrednessinlightskintonesPersistentred,blueorpurplehueindarkerskintonesPressureUlcerStagesStageII:SuperficialPartial-thicknessskinloss(epidermisand/ordermisAbrasion,blisterorshallowcraterStageIIIFull-thicknessskinloss(subcutaneousdamageornecrosisandmayextenddowntobutnotthroughfasciaDeepcraterPressureUlcerStagesStageIV:fullthicknessskinlossanddestruction,necrosisofthetissue,damagetomuscle,bone,tendonsandjointcapsulesandsinustractTypesofDressingsTransparentfilm(Tegraderm,Bioclusive)Hydrocolloid(feel)HydrogelGauzeRoll(Kerlix)ProvidemoistenvironmentLoosensloughandnecrotictissueWickdrainagefromwoundPressureUlcerAssessmentTissueTypeGranulationTissue:redandmoistSlough:yellowstringytissueattachedtowoundbed;removalessentialforhealingEschar:necrotictissuewhichisbrownorblackappearancemustbedebrided