Med Surge - Test 2 Pressure Ulcer Chapter (Red)

Front 1

Pressure Ulcers

result from tissue damage caused when?

Back 1

the skin and soft tissue are compressed between boney prominences and external surfaces for an extended period

Front 2

Pressure Ulcers


Tissue compression from pressure results in what 2 things?

Back 2

-restricts blood flow to the skin, resulting in decraese tissue perfusion

-tissue anoxia, leading to cell death

Front 3

who is at risk for developing pressure ulcers (5 people)

Back 3

Immobile patients –can’t communicate

Patients with communication deficits

Excessive exposure to moisture

Friction and shear forces

Sensory impairment

Front 4

Aspects to consider with pressure ulcers

-positioning?

-nutrition?

-skin care?

Back 4

Physical aspects

Positioning- use lift sheet to move patient. do not keep head of bed elevated above 30 degrees

Nutrition – are they a diabetic? Prone to skin breakdown. enough protein? fluid intake 2000-3000 mL/day

Skin Care -keep moisture from polonged contact with skin

Skin Cleaning –lotions, creams, cleansers, protective barriers, pat skin dry

Front 5

Stage 1 pressure ulcer

-skin intact or not intact?

-what does the area look like?

Back 5

skin is intact


the area is red and does not blanch with pressure

(blanching is when you press down and the skin turns pale and then you release and it turns pink. stage 1 do not blanch because the capillaries are already affected

Front 6

Stage II pressure ulcer

-is the skin intact or not intaact?

Back 6

not intact

Front 7

Stage II pressure ulcer

skin loss?

Back 7

Partial thickness skin loss of epidermis

Front 8

Stage II pressure ulcer

where is the ulcer?

Back 8

superficial
Ulcer is superficial (just on the top, think skinned knee, there is no depth)

Front 9

Stage II pressure ulcer

-is there brusiing?

Back 9

no it is not present

Front 10

What stage pressure ulcer?

is charcterized as an abrasion, blister, or shallow crater

Back 10

stage II pressure ulcer

Front 11

Stage III pressure ulcer

-how bad is the skin loss?

-what tissue is damaged?

Back 11

full thickness


subQ tissue may be damaged or necrotic

Front 12

Stage III pressure ulcer

how far does damage extend to?

Back 12

down to but not through the fasica, bone, tendon, or muscle

Front 13

What stage pressure ulcer

deep crater-like

Back 13

stage III

Front 14

What stage pressure ulcer?

eschar may be present

Back 14

stage III

eschar is dead tissue

Front 15

What stage pressure ulcer?

undermining may be present as well was tunneling

Back 15

stage III

Front 16

What is the difference between stage II and stage III pressure ulcers?

Back 16

depth

Front 17

Stage IV pressure ulcer

-what about the skin loss?

Back 17

it is full thickness with exposed or palpable muscle, tender, or bone

Front 18

What stage pressure ulcer

-tissue necrosis

Back 18

stage IV

Front 19

what stage pressure ulcer

-damage to muscle, bone, or supporting structure

Back 19

stage 4

Front 20

what stage pressure ulcer

-undermining is present and tunneling

Back 20

stage 4

Front 21

Unstageable pressure ulcer

-skin loss is what?

Back 21

full thickness and the base is completely covered with sloguh or eschar, obscuring the depth of the wound

Front 22

the stages of pressure ulcers are all about what

Back 22

tissue destruction

Front 23

Stage III pressure ulcer

-how bad is the skin loss?

-what tissue is damaged?

Back 23

full thickness


subQ tissue may be damaged or necrotic

Front 24

Stage III pressure ulcer

how far does damage extend to?

Back 24

down to but not through the fasica, bone, tendon, or muscle

Front 25

What stage pressure ulcer

deep crater-like

Back 25

stage III

Front 26

What stage pressure ulcer?

eschar may be present

Back 26

stage III

eschar is dead tissue

Front 27

What stage pressure ulcer?

undermining may be present as well was tunneling

Back 27

stage III

Front 28

What is the difference between stage II and stage III pressure ulcers?

Back 28

depth

Front 29

Stage IV pressure ulcer

-what about the skin loss?

Back 29

it is full thickness with exposed or palpable muscle, tender, or bone

Front 30

What stage pressure ulcer

-tissue necrosis

Back 30

stage IV

Front 31

what stage pressure ulcer

-damage to muscle, bone, or supporting structure

Back 31

stage 4

Front 32

what stage pressure ulcer

-undermining is present and tunneling

Back 32

stage 4

Front 33

Treatment of pressure ulcers

prevention:

monitoring: what do you monitor?

Back 33

Prevention: (positioning)

Monitoring : VS, Labs (serum protein), cultures, wt, effectiveness of plan (has to be assessed every shift), pt/family understanding

Positioning: every 1 to 2 hours

Front 34

treatment

keep the ulcer dry to aid in healing

true or false

Back 34

false, keep the ulcer moist

Front 35

treatment

cleanse the skin around the ulcer with mild soap and water

true or false

Back 35

true

Front 36

treatment

technique: wet to damp saline-moistened gauze

what is the mechanism of action?

Back 36

as with wet to dry technique, necrotic debris is mechanically removed but with less trauma to healing tissue

Front 37

treatment

technique: continuous wet gauze

mechanism of action

Back 37

the wound sruface is continuallly bathed with a wetting agent of choice, promoting dilation of viscous exudate and softening of dry eschar

Front 38

treatment

topical enzyme preparations:

mechanism of action:

Back 38

proteolytic action on thick, adherent eschar causes braekdown of denatured protein and more rapid sepataion of necrotic tissue

Front 39

Braden scale for pressure ulcer risk

-risk means potential for what?


-the lower or higher the number means the patient has greater risks?

Back 39

Risk means potential for the pt to have breakdown.



-The lower the number, the greater the risks the pt has for the development of skin breakdown, the greater the nursing responsibility to prevent skin breakdown *test*

Front 40

Braden scale

-Its about “risk”

-15-16 mild risk


-12-14 moderate risk,

-<11 severe risk


where does intervention start?

Back 40

15-16 mild risk

Front 41

treatment of pressure ulcers

-topical enzymes (how do they help?)

Back 41

proteolytic action

denatures protein and helps to separate necrotic tissue

Front 42

treatment of pressure ulcers

diet: what 3 things should we emphaize?

Back 42

protein

fluid intake

glucose control

Front 43

treatment of pressure ulcers

hyperbaric oxygen therapy

how does it help?

Back 43

giving oxygen at high pressures, raising the tissue oxygen concentration.

it enhances the ability of WBC to kill the infection

Front 44

treatment of pressure ulcers

surgical intervention
-2 examples:

Back 44

debridement- removal of thick, adherent wound crust with a scalpel or scissors

grafting- when full thickness ulcers cannot close

Front 45

Edema

what is it?

Back 45

swelling caused by abnormal accumulation of fluid under the skin.

Front 46

Edema

what does edema cause the skin to look like?

Back 46

to appear taut and paler than uninvolved skin

eleasticity of skin is also affected by edema

Front 47

Edema

Localized edema
-cause is from what

Back 47

inflammation response (seen with trauma)

Front 48

Edema

Dependent or pitting edema:
-cause is from what?

Back 48

fluid and electrolyte imbalance,

venous and cardiac insufficiency (Congestive heart failure, renal diseaes, hepatic cirrhosis, venous thrombosis)

Front 49

Edema

nonpitting edema
-cause is from what?

Back 49

endocrine imbalance (hypothyroidism)

Front 50

Edema is fluid accumulating in the intercellular spaces and is not normally present

true or false

Back 50

true

Front 51

How is edema assessed?

Back 51

asses for pitting edema by pressing index finger against edematous tissue to determine degree of indentation

(grading scale for 1+ for mild and +4 is deep pitting edema)

Front 52

Skin terms

dryness

Back 52

xerosis

Front 53

Skin terms


in a clean laceration or incision to be closed with sutures or staples, the act of bringing together the wound edges with the skin layers lined up in correct anatomic position so they can be held in place until healing is complete

Back 53

Approximated

Front 54

Skin terms

bruises of the skin resulting from small hemorrhages or subQ bleeding; these bruises are larger than petechiae

Back 54

Ecchymoses

Front 55

Skin terms

small, reddish purples lesions that do not fade or blanch when pressure is applied. indicate increased capillary fragility

Back 55

Petechiae

Front 56

Skin terms


large purple bruises that are sometimes raised

Back 56

Purpura

Front 57

Skin terms

bleeding under the skin either ecchymoses/petchiae depending on extent

Back 57

Purpuric lesions:

Front 58

Skin terms

a layer of black, gray, or brown nonviable, denatured collagen

Back 58

Eschar:

Front 59

Mechanical forces such as:

Back 59

pressure, friction, shear, gravity

Front 60

Mechanical foces

-pressure occurs as a result of ?

Back 60

gravity.


when a pt is positioned on a hard surface that does not diffuse the weight or when he or she remains in the smae position for too long

Front 61

Define friction


when are these forces generated?

Back 61

occurs when surfaces rub the skin and irritate or directly pull of epithelial tissue.


such forces are generated when the patient is dragged or pulled across bed linens.

Front 62

Define shear

Back 62

generated when the skin itself is stationary and the tissues below the skin (muscle, fat) shift or move.


Movement of the deeper tissue layers reduces blood supply too skin, leading to hypoxia, anoxia, ischemia, inflammation, and necrosis. pulling skin layers away from deeper tissue.

Front 63

Acne: two types most commonly seen

Non inflammatory:

Back 63

COMODOMES

black heads (open comedomes - sebaceous gland whose outlet is plugged with dirt and debri)




white heads (closed comodomes is a sebaceous outlet that is plugged and bacteria was trapped inside)

Front 64

Acne: two types most commonly seen

Inflammatory:

Back 64

cystic acne.

Have papules pustules and cysts

Front 65

Acne -Patient education related to this problem

Treatment for non-inflammatory acne

Back 65

topical creams such as: benzoyl peroxide and antibiotic salutation (noninflammatory),

Front 66

Acne -Patient education related to this problem

Treated with systemic antibiotics, such as:

Back 66

(doxy and minocycling) and BCP to affect hormone system

Front 67

Acne -Patient education related to this problem

Treated with accutane

Back 67

inflammatory acne

need to educate the pt that they need to be on birth control because accutanes is a category x drug and can cause teratogenic effects, LFT

Front 68

Wound healing:

Diabetes:
-results in what: (2)

Back 68

reduced local tissue circulation, resulting in ischemia

impaired leukocytic response to wounding, and increased probability of wound infection

Front 69

Wound healing:

Nutritional deficits:
-results in what (2)?

Back 69

impaired cellular proliferation and collagen synthesis



decreased wound contraction