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18 Cards in this Set
- Front
- Back
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skin is ___% of the bodies wt?
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15%
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Who is at risk for pressure wounds?
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dry skin
incontinence (#1 reason) diaphoresis (use powder) |
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what are 3 pressure related factors that contribute to pressure ulcer development?
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pressure intensity
pressure duration tissue tolerance |
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define shear
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gravity pushing down and resistance pushing up
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define friction?
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skin gets dragged (sheetburn) restlessness, uncontrolable movements or dragging pt when moving.
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Assessment of a wound includes
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Depth of tissue, type or stage, % of tissue in the wound, dimentions, exudate and condition of skin descrip.
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what are acute and chronic wounds?
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acute-caused from trauma or incision (easily fixed)
chronic-from repetitive insults to tissue. |
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Surgical wounds heal by _____
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primary intention (skin edges close and infection risk is down)
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chronic wounds heal by ______
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secondary intention
(wound is left open until it is filled w/ scar tissue.) |
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define dehiscence
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partial or total separation of wound layers
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define evisceration
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protrusion of visceral organs through a wound opening.
**this is an emergency** |
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what scale is used to indicate a pt's risk for pressure sores?
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norton or braden scale.
*braden is used most |
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what is a black skin wound called? yellow?
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eschar.
slough |
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what is tampanading?
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means stopping the blood.
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What are the 9 steps for assessing the wound?
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1. Location 2. size, lxW 3. depth 4. color 5. odor 6. periwound 7. exudate 8. tunneling fistula 9. undermining
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avg output for adult?
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1500 ml
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minimum avg hourly output?
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30 ml
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normal urine habits?
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5 times a day or every 3-4 hours
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