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20 Cards in this Set
- Front
- Back
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Where do you most often find pressure ulcers?
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On the sacrum
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How do the elderly get pressure ulcers?
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skin atrophy, immobilization, laying in urine or feces
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When external pressure forces are greater than capillary closing pressure, what does this cause?
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Causes tissue hypoxia and cell death.
Capillary closing pressure is defined <20 and >40 mmHg, with average of 32 mmHg |
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How do you reduce the occurence of pressure ulcers?
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Repositioning the patient every two hours.
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What does prolonged skin exposure cause?
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Tissue destruction from shear and friction forces.
Bacterial access to the subcutaneous tissue. Delayed healing of an existing wound. |
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How do you prevent maceration and ulceration in a bedridden patient?
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Creams
Management of incontinence Moisture control |
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What are 8 risk factors for pressure ulcers?
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Immobility
Joint Contraction Decreased Sensation Age Poor Nutrition Dehydration Incontinence Psychosocial factors |
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What are the 6 categories of the Braden Scale?
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1. sensory perception,
2. moisture, 3. mobility, 4. nutrition, 5. friction and shear. 6. Activity |
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How is the Braden Scale used?
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It's used to assess a patients risk of developing pressure ulcers. The lower the score the higher the risk.
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What characterizes a stage I pressure ulcer?
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observable of intact skin, include changes in color, temp, skin stiffness, or sensation/pain. Erythema.
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Define a stage 2 pressure ulcer.
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Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
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What is a stage 3 pressure ulcer?
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Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
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Define a stage 4 pressure ulcer.
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Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers.
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Should you debride a necrotic pressure ulcer?
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Yes.
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How do you treat a stage 1 pressure ulcer?
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Main goal: relieve pressure!!! Determine cause of pressure, adapt bed pressure, protect skin with ointment, protect macerated skin, or areas exposed, encourage frequent changes of position.
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How do you treat a stage 2 pressure ulcer?
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reposition patient, cleanse wound, remove any devitalized tissue, dressing if drainage, foley catherer, protect skin from maceration or friction.
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How do you treat a stage 3 or 4 pressure ulcer?
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Debride necrotic wounds.
Shallow, clean wounds can be dressed with hydrocolloid wafers, semipermeable foam, or polyurethane. Deep wounds can be packed with gauze. Antibiotics, plus lavage to remove edema and bacteria load. Help managed drainage, d/c once ok. Culture for infection and treat with antibiotics, Foam filers, non-toxic ointments |
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What is intermittant claudation a symptom of?
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symptom of muscle pain and cramping that occur with exercise.
They are vascular in origin, relieved with cessation of activities. |
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What causes stenotic claudication?
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caused by lumbar spinal stenosis and peripheral arterial occlusive disease.
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Define Thromboangiitis obliterans.
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common in smokers; symptoms: pain, tenderness, thin shiny skin, thick malformed nails, gangrene or ulcer
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