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79 Cards in this Set

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What are some risk factors for pressure ulcer development?
impaired sensory perception, impaired mobility, alteration in level of consciousness, shear, friction, and moisture
Why are patients with impaired sensory perception more likely to get pressure ulcers?
they are not able to feel when they need to move to relieve pressure
Why are people with impaired mobility more likely to get pressure ulcers?
they are unable to move to release pressure
Why does moisture increase the likely hood of getting a pressure ulcer?
moisture reduces the skin's resistance to other physical factors
Ulcers are staged on the basis of what characteristics?
depth of tissue, type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin
If you have a stage III pressure ulcer that looks to be healing towards what looks like a stage II what do you call it?
a healing stage III pressure ulcer
What is a stage I pressure ulcer?
nonblanchable redness, color differs from surrounding tissue, usually on a bony prominence
What is a stage II pressure ulcer?
partial-thickness skin loss involving epidermis, dermis, or both,
What is a stage III pressure ulcer?
full-thickness tissue loss, SubQ may be visible, may include undermining and tunneling
What is a stage IV pressure ulcer?
full-thickness tissue loss with exposed bone, tendon or muscle, often includes undermining and tunneling
What is an unstageable ulcer?
full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
What are the three processes of wound healing?
primary, secondary, and tertiary intention
What is primary intention?
union of the edges of a wound that progresses to complete scar formation without granulation
What is secondary intention?
wound closure in which the edges are separated, granulation tissue develops to fill the gap, and finally epithelium grows in over the granulation, produces scar
What is tertiary intention?
wound that is left open for several days, then the wound edges are put together
Which type of wound healing has a greater chance of infection?
tertiary
What are the three components of a partial-thickness wound repair?
inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers
What are the three components of a full-thickness wound repair?
inflammatory, proliferative, and remodeling
What are the most common complications with wound healing?
hemorrhage, infection, dehiscence, evisceration, and fistulas
Why is nutrition so important to wound healing?
deficiencies in any of the nutrients result in an impaired or delayed healing
What are the top most needed vitamins and minerals to wound healing?
protein, vitamins A and C and trace minerals zinc and copper
Why is tissue perfusion important to wound healing?
allows proper amount of O2 to enter tissues to aid in healing
What is the difference between acute and chronic wounds considering monitoring?
Acute requires frequent monitoring, Chronic requires less frequent monitoring
What are the steps of assessment?
inspection, palpation, percussion, auscultation, special
What is collagen?
a tough, fibrous protein
What is tissue ischemia?
lack of blood flow to the tissue
What is reactive hyperemia?
blanching
What is granulation tissue?
red moist tissue composed of new blood vessels
What does granulation tissue indicate?
healing
What is slough?
mass of dead tissue separating from an ulcer
What color is slough?
yellow or white tissue
What is eschar?
black or brown necrotic tissue
exudate
discharge from cells or tissue
wound
disruption of the integrity and function of tissues in the body
Hemorrhage
bleeding from a wound site
Hematoma
localized collection of blood underneath the tissues
Dehiscence
partial or total separation of wound layers
Purulent drainage
producing or containing pus, thick, yellow, green, tan or brown
Evisceration
protrusion of visceral organs through a wound opening
Serous drainage
clear, watery plasma
Serosanguineous drainage
pale, red, watery: mixture of clear and red fluid
Sanguineous drainage
bright red: indicates active bleeding
Fistula
an abnormal passage between two organs or between an organ and the outside of the body
Abnormal reactive hyperemia
surrounding skin does not blanch
Induration
hardening of tissue because of edema or inflammation
Abrasion
a superficial wound with little bleeding and is considered a partial-thickness wound
Laceration
torn jagged wound, usually bleeds more than an abrasion
Puncture
wound made by piercing the skin
Debridement
the removal of nonviable necrotic tissue
Steroids
drugs that reduce the inflammatory response and slow collagen synthesis
How often should a nutritional assessment be done for patients who are NPO?
at least every 3 months
Why type of specialty bed should be used with a stage III PU?
low air loss bed
Shear
force exerted parallel to the skin
Approximation
the act of bringing the edges of a wound together
Hemostasis
the cessation of bleeding
What is the inflammatory phase of a full-thickness wound?
the body's reaction to wounding
What is the proliferative phase of a full-thickness wound?
the appearance of new blood vessels
What is the remodeling phase of a full-thickness wound?
tissues mature and strengthen
When documenting a PU what should you include?
tissue type, size, exudate, condition of surrounding skin
What are the two PU risk assessment scales?
norton and braden
What are some examples of mechanical debridement?
wet/dry, irrigation, whirlpool
What are the four different ways of debridement?
mechanical, autolytic, chemical, surgical
What are some ways to debride a wound autolyticly?
transparent film dressings and hydrocolloid dressings
What are ways you can chemically debride a wound?
dakin's solution, maggots, topical enzyme preparation
What are the five different dressings the book talks about?
gauze, non-adherent gauze, self adhesive transparent film, hydrocolloid, hydrogel
What would you use a gauze dressing for?
absorbent for exudate
What would you use a non-adherent gauze for?
non-stick, little to no drainage, small and superficial wound
What would you use self adhesive transparent film for?
provides moist healing environment, breathable, permits viewing, (small partial-thickness wounds or to protect high risk skin)
What would you use hydrocolloid dressing for?
debridment of necrotic wounds, impermeable to bacteria (shallow or deep dermal ulcers)
What would you use a hydrogel dressing for?
hydrate and absorb small amounts of exudate (partial or full - thickness wounds)
Which dressing requires a secondary dressing?
hydrogel
Which dressing is adhesive and occlusive?
hydrocolloid
Induration
hardness of tissue
What are the five steps in the nursing procedure?
assessment, Dx, planning, implementation, evaluation
What are some sources of protein?
poultry, fish, eggs, beef
What are some sources of Vitamin C?
citrus fruits, tomatoes, potatoes, fortified fruit juices
What are some sources of Vitamin A?
green leafy veggies, broccoli, carrots, sweet potatoes, liver
What are some sources of Vitamin E?
fish, oysters, liver, dark meat, eggs, legumes
What are some sources of Zinc?
veggies, meats, legumes