Core Concepts Module 4

Front 1

What is Shearing Forces?

Back 1

....results when one tissue layer slides over another.

Front 2

Microthrombi

Back 2

Microthrombi impede blood flow, and result in ischemia & hypoxia of tissues.

Front 3

During inflammatory response, patient can experience....

Back 3

Increased :

Temperature, pain, WBC's

Front 4

A pressure (decubitus) ulcer is?

Back 4

.... A specific type of tissue injury from unrelieved pressure or friction over bony prominences that results in ischemia and damage to the underlying tissue.

Front 5

Why does drainage (exudate) occur?

Back 5

It occurs as a result of the healing process and occurs during the inflammatory and proliferative phases of healing.

1g = 1mL of drainage.

Most accurate measurement is to weigh the dressing.

Front 6

Primary intention healing

Back 6

Example-- surgical incision.

Front 7

Secondary intention healing

Back 7

Front 8

Tertiary or delayed primary intention healing

Back 8

Front 9

Patients with greatest risk of pressure ulcers are:

Back 9

Those with spinal cord injuries, hospitalized patients, and patients in LTCF

Front 10

Factors affecting skin integrity

Back 10

Genetics & heridity, age, chronic illness & its treatment, medications, poor nutrition

Front 11

Risk Assessment Scales

Back 11

Norton and Braden scales

Braden - for predicting pressure sore risk

23 is total points... 18 or lower is at risk.

Norton- pressure area risk assessment form scale

Possible score of 24 & 15-16 = viewed as indicators of pressure ulcer development

Front 12

Stages 1 Pressure Ulcer

Back 12

NONBLANCHABLE erythema signaling potential ulceration

Front 13

Stage 2 Pressure Ulcer

Back 13

Partial- Thickness skin loss involving epidermis and possible dermis. Presents as a shallow open ulcer WITHOUT SLOUGH.

Front 14

Stage 3 Pressure Ulcer

Back 14

Full-thickness skin loss involving damage or necrosis of subcutaneous tissue - slough may be present in this stage. Appears as a deep crater with or without undermining or tunnelling

Front 15

Stage 4 Pressure Ulcer

Back 15

Full- thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures - bone, tendons, muscles are exposed and palpable- slough and eschar may be present.

Front 16

Inflammatory Phase

Back 16

Swelling

Begins directly after the injury occurs - typically lasts about 3-6 days, phagocytosis,

Front 17

Proliferative Phase

Back 17

Scabs over

Begins approx. On day 3 or 4 and continues until around day 24. Collagen synthesis begins in this phase. Granulation tissue forms in this phase as well. Contracts the wounds edges. Resurfaces new epithelial cells. -susceptible to bleed easily!!!!!

Front 18

Maturation phase or remodeling phase

Back 18

SCARS

Occurs on day 21 and can last up to one to two years from when injury occurred. Wound is remodeled- scar tissue is formed and strengthing.. Will never be the same as it was before it was injured.

Front 19

Hemmorhage

Back 19

EXCESSIVE BLEEDING! not normal.

Front 20

Infection

Back 20

-difficult to determine when it happened and the underlying cause..

Impossible to keep EVERYTHING sterile.

Hand hygeine.

-total hip replacement- infection- severe infection- can lead to futher surgery or implants be removed completely.... So no hip joint. Etc.

Front 21

Assessment/ Data Collection

Back 21

Red: healthy regeneration of tissue. (Protect, cover)

Yellow: presence of purulent drainage or slough. (Clean)

Black: presence of eschar that hinders healing and requires removal. (Debride, removal of necrotic tissue)

Use a clock face with 1200 towards the clients head to document the location of sinus tracts.

Front 22

Serous Drainage

Back 22

Portion of the blood that is watery and clear or slightly yellow in appearance. (Fluid in blisters)

Front 23

Sanguineous

Back 23

Serum & red blood cells. Thick and red. Brighter= fresher drainage.

Front 24

Serosanguineous

Back 24

Serum and blood. Watery and appears blood streaked or blood tinged.

Front 25

Purulent Drainage

Back 25

The result of infection. Thick. Contains white blood cells, tissue debris, and bacteria. Yellow, tan, brown, depending on infectious organism. Foul odor!!!

Front 26

Purosanguineous

Back 26

Mixed drainage of pus and blood such as a newly infected wound.

Front 27

Protein Foods

Back 27

Meat, fish, poultry, eggs, dairy, beans, nuts, whole grains.

Front 28

Albumin.

Back 28

If below 3.5 = lack of protein means increase in delay of wound healing and infection.

Front 29

Wound Cleansing

Back 29

Front 30

Wound Dressings

Back 30

Front 31

Dehiscence & evisceration

Back 31

"Re-opened." Partial or total rupture (seperation) of a sutured wound, usually with seperation of underlying skin layers. Typically 4-5 days post op. {Sterile towel with normal saline}