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25 Cards in this Set
- Front
- Back
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What causes a pressure ulcer? |
Pressure Blanching Tissue tolerance |
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What are some risk factors for developing pressure ulcers? |
Moisture Pain Friction Infection Nutrition Impaired mobility |
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What is a stage 1 pressure ulcer? |
Skin is intact Nonblanchable redness No skin opening |
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What is a stage 2 pressure ulcer? |
Partial skin loss involving epidermis, dermis, or both |
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What is a stage 3 pressure ulcer? |
Full thickness tissue loss with visible fat |
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What is a stage 4 pressure ulceR? |
Full thickness tissue loss Exposed bone, muscle or tendon |
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What is an unstageable pressure ulcer? |
Full thickness tissue loss Base of ulcer is covered Can't see how deep it is |
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What is a wound? |
A disruption of the integrity and function of tissues in the body |
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What are the 2 types of wounds? |
Acute and Chronic |
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What are the 3 stages of the healing process? |
Primary intention Secondary intention Tertiary intention |
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What is an acute wound? |
Heals in an orderly and timely process (surgical incision and trauma) |
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What is a chronic wound? |
Wound that doesn't proceed through an orderly and timely process (vascular problems) |
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What happens in primary intention? |
No tissue loss Wound edges are approximated Low infection risk heals quickly little scarring |
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What is secondary intention? |
tissue loss edges not approximated heal slowly by granulation high infection risk take longer to heal larger scars |
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What is tertiary intention? |
Wound left open for days then edges are approximated Wound closure is delayed until infection risk is gone Don't tend to suture again (binding) |
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What is partial thickness wound repair? |
Take less time to heal Shallow and loss of epidermis Inflammation stage, proliferation and migration stage, re-establishment of layer stage |
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What is full thickness wound repair? |
Take longer to heal Wound extends into dermis Heal by scar formation Inflam stage, proliferative phase, remodelling phase |
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What happens in the inflammation phase? |
Hemostasis Inflammation WBCs Epithelialization |
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What happens in the Proliferative phase? |
Wound begins to fill with granulation tissue Top of wound closes over Growth of epithelial cells |
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What is the remodelling phase? |
Collagen scar tissue continues to reorganize and gain strength for many months |
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What are venous wounds? |
Superficial, irregular shape Lots of exudate Brownish colour |
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What are arterial wounds? |
Purched out Deeper and smaller Reddish or purpleish |
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What are surgical wounds? |
Approximated edges, low infection risk, little tissue loss, heal by primary intention |
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Types of wound drainage? |
Serous (clear, liquidly) Purulent (pus) Serosanguineous (pale red, watery) Sanguineous (clots) |
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What is dehiscence, evisceration, fistula formation? |
- edges come apart - edges separate and expose organs - passageway from one organ to another, or to skin surface |
