Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
79 Cards in this Set
- Front
- Back
|
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
|
