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41 Cards in this Set

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  • Back
What is the function of the dermis?
Strength, mechanical support, and protects
What intention has little tissue loss, inflammation subsides in less than 24 hrs, and resurfaces in 4 to 7 days?
primary intention
What intention has loss of tissue, fills with scar tissue, chance of infection is greater?
secondary intention
What is the loss of epidermis and partial loss of dermis?
partial thickness
What regenerates in partial thickness?
epidermis
What is wound repair when the wound extends into the dermis and perhaps beyond?
full thickness
What is thickness where deep structures do not regenerate and heal by scar?
full thickness
How long does the inflammation response occur in partial and full thickness/?
partial- 24 hrs
full 3 days
What are the 3 phases of full thickness healing?
inflammatory phase,proliferate phase, and remodeling
What occurs during the inflammatory phase in full thickness?
-3 days
-hemostatsis
-clot
-leukocytes,macrophages,and fibroblasts released
What occurs during the proliferate phase?
3-24 days
-granulation tissue
-contracts
-epithelization
What occurs in remodeling?
could last a whole year
collagen scar reorganizes and strengthens
whiter with less melanin
What is when layers under structures and tissues separate?
dehisence
What is when the wound seperates and bowel or bone shows?
evisceration
What is evisceration due to?
Obesity and poor nutrition
What is a pressure ulcer?
Impaired skin integrity related to unrelieved, prolonged pressure
What are the three factors of pressure ulcers?
time,pressure,tissue tolerance
Tissues are first what in ulcers and then what?
hypoxic then necrotic
When does tissue damage occur in ulcers?
Capillaries occluded (16-32 mm HG
What is a decrease in 02?
hypoxia
What is a occluded vessel or lack of blood flow?
ischemia
What is tissue death?
necrosis
What is when the pressure is relieved and blood flow returns? Skin turns red?
reactive hyperemia
What is condition called if skin is transient?
can blanch in area of reactive hyperemia
How long can low pressure be applied before a bed bound person gets an ulcer?
2 hours
What is degrees to not let bed above to prevent shear and friction?
30 degrees
What is assessments for transient hyperemia?
redness after ischemia..but blanches and lasts less than 1 hour
What is when skin is bright pink to red and does not blanch, but lasts more than 1 hour?
abnormal reactive hyperemia
What are some indications at risk for breakdown in dark skin?
darker than surrounding skin, blue or purple, natural light needed, temp, turgor, induration, and sensations
What type of ulcer has intact skin but persistent red or blue with temp change and altered sensations?
stage 1
What type of ulcer has partial thickness which appears to be a shallow abrasion or blister?
stage 2
What ulcer has full thickness, damage or necrosis of subq tissue, to fascia?
stage 3
What ulcer has severe pain in heels, cannot be seen on surface, looks sick, feels sick, anorexic, tunnel or undermine and damages to fascia?
stage 4
6 risks for ulcers
-reduced risk of sensation,moisture,shear/friction/devices rubbing,impaired motor function,level of consciousness
In Braden score what is at risk?
16 0r 18
What is perfect score for braden and what means if score is lower?
23..lower score the worse the risk
6 areas most at risk for ulcers?
sacrum,heels,elbows,lateral malleoli,greater trochanter,ischial tuberosities
When is the only time to keep wounds dry?
arterial circulation problem
What should you be careful of if there is a problem with arterial circulation?
problems with tips of toes and between toes
How do you dress a surgical wound with primary intention?
apply dressing until drainage ceases, leave open to air, use gauze
How do you dress a surgical would with secondary intention?
provide moisture to wound, and assist in debridement