Nur 151 Chapter 48 Skin Integrity And Wound Care

Front 1

Risk Factors for Pressure Ulcers

Back 1

decreased mobility, decreased sensory perception,
fecal or urinary incontinence, and/or poor nutrition

Front 2

assessment of pressure ulcers

Back 2

1. depth of tissue involvement (staging)
2. type and % of tissue in wound bed
3. wound dimensions
4. exudate description
5. condition of surrounding skin

Front 3

staging with nercrotic tissue involves what step

Back 3

the depth cant be viewed until necrotic tissue is removed to expose wound base

Front 4

Staging levels include:

Back 4

Stage I: Nonblanchable Redness of Intact Skin

Stage II: Partial-thickness Skin Loss or Blister

Stage III: Full-thickness Skin Loss (Fat Visible)

Stage IV: Full-thickness Tissue Loss (Muscle/Bone Visible)

Front 5

Stage I: Nonblanchable Redness of Intact Skin

Back 5

Intact skin presents with nonblanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching.

Front 6

other names for pressure ulcer

Back 6

- pressure sore
- decubitis ulcer
- bedsore

Front 7

pressure ulcer

Back 7

localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction

Front 8

3 pressure related factors that contribute to pressure ulcers are

Back 8

(1) pressure intensity,
(2) pressure duration,
(3) tissue tolerance.

Front 9

tissue ischemia

Back 9

Point at which tissues receive insufficient oxygen and perfusion

Front 10

tissue tolerance factors

Back 10

1. extrinsic factors - shear, friction, and moisture

2. underlying skin structures (blood vessels, collagen) assist in redistributing pressure.

3. Systemic factors - poor nutrition, increased aging, hydration status, and low blood pressure

Front 11

eschar

Back 11

black or brown necrotic tissue - (Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed)

Front 12

Granulation tissue

Back 12

red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing

Front 13

slough

Back 13

soft yellow or white tissue - stringy substance attached to wound bed that must be removed for healing

Front 14

exudate

Back 14

Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes.

Front 15

wound exudate should describe the

Back 15

the amount, color, consistency, and odor of wound drainage and is part of the wound assessment