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102 Cards in this Set
- Front
- Back
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Examples of external pressure:
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Bed
Chair Pillow on Skin (happens above bone) |
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Term used for most susceptible tissue:
(thin skin) |
Tissue Tolerance
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Term used for 2 surfaces rubbing together
(Ripping skin with gloves) |
Friction
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Term used for one layer of tissue sliding over another:
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Shearing Forces
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Biggest risk factors for shearing forces:
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Immobility
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Most common area of pressure:
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Skin over bone:
Elbow Inner knee Back of head Coaxial |
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Examples of Immobility:
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Long Surgery
Unconsciousness Paralysis |
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Why is protein important for pressure ulcers:
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Promotes healing
Albumin levels are checked (protein status) which promotes wound healing |
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What happens in vitamin c deficiency:
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Capillaries become very fragile
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What are normal glucose levels:
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70-110
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Why is Fe important:
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Transport O2
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Why is zinc important:
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Granulation tissue formation
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Why is hydration important:
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Fluids transport minerals
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Term used when the skin becomes soggy and flimsy due to being soaked in fluid: (over saturation)
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Maceration
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Why is mental status important in pressure ulcer care:
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The confused cannot understand when/why they are hurt;
Apathetic don't care they are hurt or cannot tell they are in pain; Comatose |
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Why are older clients more at risk:
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More diseases (heart/diabetes)
Respiratory (not enough O2) Fractures (immobility) Corticosteroids (decrease immune function and skin durability) |
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Why are obese at risk for pressure ulcers:
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Adipose tissue decreases water content
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What are the stages of pressure ulcers based upon:
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Necrosis
Tissue Level |
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State of pressure ulcer is not based upon:
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Deepness
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Can pressure ulcers be 're-staged'?
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No
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Stage I Pressure Ulcer Description:
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1 redness does not go away when turned (purple on dark skin)
2 Non blanchable (press doesn't turn whte) 3 Feels spongy |
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Stage I Treatment:
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1 Pressure Relieving Devices
2 Frequent q2 hrs turning 3 Do not message |
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Sage II Pressure Ulcer Description:
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Dermis or Epidermis (partial break in skin)
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Sage II Treatment:
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1 Dressing (transparent film)
2 Hydrocholoid (moist wound environment) 3 Maintain moist wound environment) |
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Stage III Pressure Ulcer Description:
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1. Subcutaneous
2. Slough Tissue (stringy-white/yellow) 3. Sacral Wounds (necrotic tissue) |
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Stage III Treatment:
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1. Wet to dry dressing - clean with saline
Protolytic Enzyme Debride |
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Stage IV Pressure Ulcer Description:
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Muscle and Bone deterioration
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Stage IV Treatment:
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1. Wound Vac (large deep wounds)(moist but not too moist) - stimulation of granulation formation
2. Surgery (Skin graft) 3. Debride 4. Protolytic Enzyme |
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Term used for tunnel into skin:
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Tunneling
Stage III + IV |
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Term used for when damaged layers spread apart and you can sweet between them"
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Undermining
Stage III + IV |
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Term used to cutting dead tissue away:
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Debride
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Enzyme that dissolves dead tissue:
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Protolytic Enzyme
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What location do you color classify the wound:
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Wound Base
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Description of red wounds:
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Clean
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Description of yellow wounds:
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sloth (fibrous tissue)
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Description of black wounds:
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Necrotic Tissue
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Term used for a black wound that is thick and is scab like:
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ESCHAR
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There is difficulty staging which kind of wound:
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Black wounds
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Term used for bumpy, beef red tissue which is moist and fragile:
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Granulation Tissue
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Term used for the top layer of skin that is regrown from the inside out and is dry and shiny:
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Epithelialization
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Term used for drainage that is clear and watery:
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Serous Drainage
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Term used for drainage that is pus and creamy thick, not always white, and can have a foul odor (infected)(can be necrosis)
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Purulent Drainage
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Term used for drainage that is bloody:
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Sanguineous Drainage
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Term used for drainage that is bloody and watery:
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Serosangineous Drainage
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Procedure that ID's the type of wound then is ran against antibiotics for up to 3 days
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Wound Culture and Sensitivity
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Lab Value that indicates infection
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WBCs (>11k)
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Lab Values - Normal WBC (Adult):
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4.5k-11k
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Lab Values - Normal Albumin (Adult):
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3.4-4.8
<3.4 = bad |
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Lab Values - Normal Hgb (Adult Male):
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13.2-17.3
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Lab Values - Normal Hgb (Adult Female):
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11.7-15.5
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Lab Values - Normal Htc (Adult Male):
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43-49
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Lab Values - Normal Htc (Adult female):
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38-44
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Lab Values - Normal Glucose:
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70-110
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What happens when glucose >110?
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Impairs Circulation
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what scale do you use to assess a pressure ulcer?
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Braden Scale
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What number on the Braden scale is high risk?
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>9
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What number on the Braden scale is no risk?
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19-23
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How do you measure the Braden Scale:
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Subjective to measure Objective
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What is the Braden scale based upon:
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Sensory
Moisture Activity Mobility Nutrition Friction |
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How often do you assess pressure ulcers:
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Beginning of every shift and as needed.
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What do you chart when assessing a pressure ulcer?
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Location
Size Stage Wound Bed Drainage Wound Edges Mobility Nutritional Status Moisture and Incontinence Smoker |
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How do you chart the location:
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Exact Location
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How do you chart the size:
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usually in cm (LxWxD)
first notice + every day or 2 |
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How are stages charted:
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Can only stage upward
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How do you chart wound bed:
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By presence of granulation and necrotic tissue
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How do you chat Drainage:
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How much (saturation)
Type of drainage (serous) Foul Odor Purulent (pus) - Dime size |
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How do you document Wound Edges:
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Are they clean? Are they jagged?
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How do you Document Mobility?
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Can they turn and will they remember to turn?
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How do you document nutritional status:
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Ask what/how much they are eating
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How do you document moisture and Incontinence:
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Are they sweating?
incontinent drainage - can they control their bowels |
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Why do you document if they are a smoker?
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Smoking decreases circulation and blood vessels
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How do you measure depth, tunneling, and undermining?
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Q Tip
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What kind of calories do you want pts. with pressure ulcers taking in?
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Protein and Fiber and Increase water intake
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Why is body weight changes important to pressure ulcers:
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If their weight decrease by more than 15% they are at high risk for developing pressure ulcers.
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Why is zinc important for pressure ulcer care:
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Granulation formation
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Why is iron important for pressure ulcer care:
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O2 transportation
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Term used for nutrition that bypasses the GI system, used through an IV:
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Parenteral Feeds
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Term used for nutrition that goes through the GI usually though a nasogastric tube:
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Eternal Feeds
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How do you measure pain from pressure ulcers:
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Pain scale and Nonverbal Cues
(Usually very painful) |
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What are some proper diagnosing of pressure ulcers though the nursing process:(6)
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1. Impaired Skin Integrity
2. Acute Pain 3. Risk for Infection 4. Self Care deficit 5. Impaired Physical Mobility 6. Knowledge Deficit |
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What is proper planning of pressure ulcers through the nursing process:
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Client Needs (Mutual Goals)
Prevention of Complications Potential Risk Measurable - Ulcer will decrease by 2mm in 2 weeks |
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What are some proper implementations of pressure ulcers through the nursing process:
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Prevention
Teaching Treating |
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A chemical used for keeping the wound from getting infected
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Mesalt
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Impaired skin integrity vs impaired tissue integrity indicates:
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Stage of ulcer
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How do you treat the skin around the wound:
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Keep good skin dry and clean (don't allow maceration)
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How do you support the surfaces of pressure ulcers:
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Pressure reducing and relieving devices:
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What are some types of dressings:(7)
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1. Saline: wet to dry
2. Transparent Films - Op site or Tegaderm 3. Hydrocolloid- Duoderm (II) 4. Hydrogels - Aquasorb 5. Alginates - Sorban 6. Foams - Allevyn 7. Silver Dressings - SilvaSorb |
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What is an Alginate dressing?
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Feathery like material into the wound
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How would you evaluate?
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Evaluate nursing measure and outcomes
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Why would you make referrals to get someone else involved:
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If there is no improvement
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What are you constantly doing to the pt for knowledge:
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Constantly Teaching
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type of wound that is cutting or or sharp instrument; wound edges in close approximation and aligned:
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Incision
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type of wound that was caused by a blunt instrument. The overlying skin remains intact, with injury to the underlying soft tissue. Possible result in bruising and or hematoma
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Contusion
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Type of wound that is caused by friction, rubbing or scraping epidermal layers of skin; top layer of skin is abraded:
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Abrasion
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Type of wound where the tearing of skin and tissue with blunt or irregular instrument; Tissue is not aligned; often with loose flaps of skin and tissue:
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Laceration
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Type of wound caused by a blunt or sharp instrument puncturing the skin; intentional (venipuncture), or accidental
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Puncture
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Type of wound that is described as tearing a structure from normal anatomical positions; Possible damage to blood vessels, nerves, and other structures:
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Avulsion
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Type of wound that is caused by secretion of exotoxins or release of endotoxins by living organisms
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Microbial
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Type of wound that is caused by a toxic agent such as drugs, aids, alcohols, metals, and substances released from cellular necrosis
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Chemical
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Type of wound that is caused by high and low temperatures; Cellular necrosis is a possible result:
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Thermal
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Type of wound that is caused by ultraviolet light or radiation exposure
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Irradiation
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term used for deficiency of blood in a particular area
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Ischemia
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