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140 Cards in this Set

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(def)

any lesion caused by unrelieved pressure that results in damage to underlying tissue; formerly called decubitus ulcers, bed sores, pressure sores
Pressure Ulcers
(def)

a combination of friction and pressure that, when applied to the skin, results in damage to the blood vessels and tissue
shearing force

aka- shear
(def)

rubbing; the force that opposes motion
friction
(def)

the source or cause of an illness or abnormal condition
pathogenesis
(def)

includes actions such as positioning and repositioning, head-of-the-bed elevation, selection of support surfaces, and moisture consideration
Tissue load management
(manage tissue load)
(def)

thick necrotic tissue produced by burning, by a corrosive application, or by death of tissue associated with loss of vascular supply, bacterial invasion, and putrefaction
eschar
What are 2 scales used to identify a client's risk for pressure ulcers?
Braden Scale
Norton Scale
Pressure ulcers may be described as having _______ or _______ thickness skin loss.
partial or full thickness skin loss
(def)

a salt of alginic acid, extracted from marine kelp; preparations have been used in foam, cloth, and gauze for absorbent surgical dressings
alginates
(def)

a gel in which water is the dispersion medium
hydrogel
(def)

a clear, sterile dressing made of a thin and flexible polyurethane film; adhesive plastic semipermeable nonabsorbent dressings
transparent film
(def)

a type of dressing containing gel-forming agents; waterproof, adhesive wafers, pastes, or powders
hydrocolloid dressing
(def)

removal of infected and necrotic tissue
debridement
(def)

the use of scalpel, scissors, or other sharp instrument to remove devitalized tissue
sharp debridement
(def)

the use of wet-to-dry dressing, hydrotherapy, or wound irrigation to remove devitalized tissue
mechanical debridement
(def)

the application of topical debriding enzymes to devitalized tissue on a wound surface
enzymatic debridement
(def)

debridement using dressings that are applied to the wound to allow necrotic tissue to self-digest by the action of enzymes present in wound fluids; contraindicated in infected wounds
autolytic debridement
What agency sets the standards for pressure ulcer management?
AHRQ (Agency for Health Care, Research, and Quality)
How are the standards for pressure ulcer management determined?
using Evidence Based Practice
In the US, how many estimated cases of pressure ulcers are there in the US each year?
1.5 - 3 million
What percent of pressure ulcer cases are estimated to occur in an acute care environment?
7-9%
What percent of pressure ulcer cases are estimated to occur in long-term facilities?
2.3 - 28%
What percent of pressure ulcer cases are estimated to occur in home care settings?
0-29%
What percent of pressure ulcer cases occur in elderly patients with femoral fractures?
66%
What percent of pressure ulcer cases occur to the critical care population?
33%
What is the mortality rate for pressure ulcers?
5%
What is the average cost in US dollars as a result of pressure ulcers per year?
1.3 billion
What is the utmost problem caused by pressure ulcers, one that cannot be measured?
the cost in human dignity
What specialized nurses society is widely recognized for input into the pressure ulcer prevention and treatment guidelines?
Wound Ostomy and Continence Nurses Society
The Clinical Practice Guidelines issued by the Wound Ostomy and Continence Nurses Society focuses on guidelines in what (3) areas?
- pressure ulcers
- lower extremity ulcers
- bowel and bladder diversions
(def)

localized area of tissue injury / cellular necrosis produced from lack of blood flow due to pressure between a bony prominence and external surface
pressure ulcer
When does pressure on a body surface become a problem?
when the pressure exerted on the capillaries exceeds the pressure within the capillaries
What are (3) common sites for pressure ulcers?
- sacral
- trochanter
- heels
What is the purpose of a Lunax Boot?
Serves as a heel protector
What is the most common wheelchair/sitting pressure point?
ischial tuberosity
Describe what occurs during shearing force.
The tissue is pulled, causing layers to slide on each other
What is the largest problem with shear?
it causes blood vessels to be stretched and constricted
What is friction?
a superficial mechanical force rubbing against the skin (ex. skin rubbing against bed sheets)
Prolonged, excessive moisture can result in what?
maceration
What are the (4) pathogenesis of a pressure ulcer?
1. pressure
2. shear
3. friction
4. moisture
How does immobility contribute to pressure ulcers?
increases pressure
How does moisture contribute to pressure ulcers?
causes maceration
How does heat/fever contribute to pressure ulcers?
increases metabolic needs; decreases nutrition to ulcer
How does poor hygiene contribute to pressure ulcers?
skin irritation due to waste accumulation
How do diseased conditions contribute to the development of pressure ulcers?
alters the ability of skin/tissue to respond to pressure
How does edema contribute to pressure ulcers?
tissue fluid increases pressure on blood vessels
How does obesity contribute to pressure ulcers?
fatty tissue has decreased blood supply
How does debilitation contribute to pressure ulcers?
weakened skin integrity
How does malnutrition contribute to pressure ulcers?
causes dry, scaly, peeling skin; increases the risk for skin breakdown
How does damaged tissue contribute to pressure ulcers?
more susceptible to breakdown
How does an altered mental status contribute to pressure ulcers?
less able to respond to pain/pressure
A Braden Scale Score of 23 indicates what?
little or no risk of pressure ulcer development
A Braden Scale score of 15-18 indicates what?
low risk of pressure ulcer development
A Braden Scale score of 13-14 indicates what?
moderate risk of pressure ulcer development
A Braden Scale score less than/equal to 12 indicates what?
a high risk for pressure ulcer development
A Braden Scale score of 9 or below indicates what?
A very high risk for pressure ulcer development
Which Stage of a pressure ulcer?:

Erythema that does not go away and does not blanch
Stage 1
Which Stage of a pressure ulcer?:

Discoloration of dark skin, warmth, edema, induration
Stage 1
Which Stage of a pressure ulcer?:

Partial thickness skin loss involving epidermis, dermis, or both
Stage 2
(Def)

redness due to localized vasodilation that lasts less than one hour
hyperemia
Which Stage of a pressure ulcer?:

Shallow crater
Stage 2
Which Stage of a pressure ulcer?:

abrasion or blister
Stage 2
Which Stage of a pressure ulcer?:

full-thickness skin loss involving damage or necrosis of the subcutaneous tissue which may extend to the fascia
Stage 3
Which Stage of a pressure ulcer?:

deep crater, may have undermining
Stage 3
Which Stage of a pressure ulcer?:

full-thickness skin loss with extensive destruction and tissue necrosis
Stage 4
Which Stage of a pressure ulcer?:

damage to muscle, bone and tendon; may have undermining
Stage 4
What are the 3 goals of prevention of pressure ulcers?
1. Manage tissue load
2. Keep skin clean, dry, intact
3. Maintain good nutrition
To manage tissue load, you want to accomplish what 2 goals?
1. prevent sustained pressure
2. minimize shear and friction
To prevent sustained pressure, you want to use ____ degree turns.
30
How often should a person be repositioned?
every 2 hours
You should use a _______ schedule for turning.
written
What type of items can be used to assist with prevention of sustained pressure?
pressure reducing mattresses (alternating air / sustained air), chair cushions, pillows, therapeutic beds
How often should a person in a wheelchair be repositioned manually?
every hour
If a client is able to, you want to teach them to shift their weight every ____ mins.
15
True/False:

Donut-type devices provide the best heel protection.
False- you should NEVER use donut-type devices
How should you relieve heel pressure?
You want to totally relieve pressure on the heels. Do this by placing legs on a small pillow/towels to float the heels.
What is the purpose of utilizing proper moving and positioning techniques?
to minimize shear and friction
To minimize shear/friction, how should the bed be positioned?
flat or a maximum of 30 degrees
What are examples of items that can be used to minimize shear and friction?
skin barrier, soft socks, long sleeves
How often should you assess a client's skin?
At least daily (and document findings)
What should you specifically pay attention to when assessing skin?
bony prominences
True/False:

You should massage bony prominences/reddened areas to facilitate healing.
False- you never massage these areas
True/False:

Skin should be cleaned at the time of soiling.
true
True/False:

Hot water helps to facilitate the healing process and prevents the development of pressure ulcers.
False- hot water should be avoided
What type of soap should be used on patients?
mild soap (minimize friction, rinse thoroughly and pat dry)
True/False:

Diaper use should be limited to avoid the development of pressure ulcers.
True
What should be done to dry skin? What areas are of specific concern for dryness?
moisturize areas, pay close attention to feet, elbows, and back
To maintain good nutrition, you should encourage what 3 things?
fluid, calories, and protein
What is the purpose of monitoring serum albumin?
indicator of nutritional status
What is the normal range for serum albumin? What range indicates a compromised protein status?
3.5 - 5.0 = normal range
2.8 - 3.5 = compromised protein status
What should be provided to clients who are nutritionally compromised?
nutritional supplements (ensure, vitamins, minerals)
What are 2 external skin substances that should be avoided?
- alcohol
- talc powder
You should monitor lab values for any client with nutritional issues. What is the normal hemoglobin range? What is a normal WBC count?
Hemoglobin = men - 13-16 g/100 mL
Hemoglobin = women - 12-16 g/100 mL

WBC = 4,500-11,000/mm
What are your (4) nursing interventions for a Stage 1 Pressure Ulcer (Erythema - non-blanching)?
1. incorporate all preventative measures
2. use ointments (A&D, Aloe Vesta)
3. Employ transparent film (on non-fragile skin)
4. May use hydrocolloids
What guideline should be followed when applying a transparent film to a Stage 1 pressure ulcer?
always apply on non-fragile skin
What are your (3) nursing interventions for a Stage 2 Pressure Ulcer (Excoriated Skin, Epidermal/Dermal)?
1. Employ all Stage 1 measures
2. Cleans with saline (or hospital protocol); do NOT scrub
3. Apply hydrocoilloid or transparent film to non-infected wound
What should be done to the skin surrounding a pressure ulcer prior to taping?
Use a preparation to protect the surrounding skin (skin gel or hospital protocol)
What is the overall purpose of transparent films?
- to provide a moist environment and protect against contamination
A new ointment called xenaderm is recommended for perineal wounds. What are 4 actions of this ointment?
1. increases blood flow
2. creates moist environment
3. acts as a protective covering
4. aids in pain reduction
What is the purpose of hydrocolloids? (4)
- absorbs light exudates
- produces moist environment
- protects wound from contamination
- prevents shearing
What are your (5) nursing interventions for Stage 3 pressure ulcers?
1. Incorporate Stage 1 & 2 measures
2. Debride as prescribed
3. treat infections
4. apply dressings
5. encourage granulation
Partial thickness ulcers should show evidence of healing in how long?
1-2 weeks
Full-thickness ulcers should show evidence of healing in how long?
2-4 weeks
(def)

removal of necrotic tissue so that healthy tissue can regenerate
debridement
Surgical/Sharp debridement may be indicated when?
signs of advancing cellulitis or sepsis are present
What is the largest advantage of surgical/sharp debridement?
it is the most rapid form of debridement
What are the largest disadvantages of surgical/sharp debridement? (3)
- clinical skill is needed
- may require moving the client to a special procedure/operating room
- requires pain control measures
Mechanical debridement may be done using what (3) methods?
1. wet-to-dry dressings
2. hydrotherapy (ex. whirlpool)
3. wound therapy (ex. irrigation)
Describe the syringe that should be used form mechanical debridement.
35 mL syringe with a 19 gauge needle/catheter designed to deliver 8 psi
What is the largest advantage of hydrotherapy and irrigation, methods used in mechanical debridement?
can be used to cleanse granulating wounds and soften eschar
What is the largest disadvantage of wet-to-dry dressings, a method of mechanical debridement?
they are non-selective, removing both nonviable and viable tissue
True/False:

A nurse can initiate an order for enzymatic debridement.
False - a physician's order is required for the drugs needed for enzymatic debridement
(def)

the application of topical debriding enzymes to the devitalized tissue on the wound surface
enzymatic debridement
(def)

method of debridement where dressings are applied to the wound to allow necrotic tissue to self-digest by the action of enzymes present in wound fluids
autolytic debridement
True/False:

Autolytic debridement is the best method for infected wounds.
False- it is contraindicated in infected wounds
What type of solution should be used to irrigate an infected pressure ulcer? What should be avoided?
Normal saline should be used; avoid the use of betadine or hydrogen peroxide
What (2) types of antibiotic mediums are often used in infected pressure ulcers?
- antibiotic powder
- antibiotic ointment
What (2) dressings are used for stage 3 pressure ulcers with infection and exudates?
1. alginates
2. hydrogels
What 2 actions do alginates (a dressing for stage 3 wounds with infection and exudate) exert?
1. absorb exudate
2. eliminate dead space
What 2 actions do hydrogels (a dressing for stage 3 wounds with infection and exudate) exert?
1. liquefy necrotic tissue
2. fill in dead space
(def)

formation of new, highly vascular tissue in a healing wound
granulation
What are 2 things that should be done to encourage granulation?
1. continue wound care as prescribed
2. maintain good nutrition
What are (5) nursing interventions for Stage 4 pressure ulcers?
1. All Stage 3 measures
2. consider special beds
3. sharp debridement
4. assess for undermining
5. assess for complications of osteomyelitis and sepsis
True/False:

Sharp debridement should be done only by a person trained/specialized in that area of care.
True
What is the RYB code?
Protect RED
Cleanse YELLOW
Debride BLACK
In the RYB code, what type of tissue is considered "red"?
granulation tissue
In the RYB code, what type of tissue is considered "yellow"?
Semi-liquid slough with purulent drainage
In the RYB code, what type of tissue is considered "black"?
eschar
In what order do you treat tissue using the RYB code?
Treat the most serious color first:

1. Black
2. Yellow
3. Red
What are (3) rules for protecting "Red" tissue, aka granulation tissue?
1. gentle cleansing
2. avoid use of dry gauze and wet-to-dry gauze
3. apply transparent film & hydrocolloid
What are (2) rules for cleansing "Yellow" tissue, aka slough?
1. apply antimicrobials
2. cleanse to remove nonviable tissue
What is the treatment method for eschar, aka "black" tissue?
debridement
Overall, what are your 8 primary nursing goals when managing pressure ulcers?
1. manage tissue load
2. prevent maceration
3. treat infection
4. encourage granulation
5. protect surrounding skin
6. improve nutrition
7. encourage client participation and responsibility
8. teach client and family about preventative measures
What guidelines should be followed when collecting a specimen for a wound culture?
1. clean with normal saline first
2. culture swab should be sterile as well as the container it is placed in
3. culture must be kept in a moist medium
What are 3 examples of adjunct wound care products?
1. Mist Therapy
2. Super oxidized water
3. Vacuum-Assisted closure device
A Wound VAC is contraindicated in what 4 cases?
1. malignancy
2. untreated osteomyelitis
3. necrotic tissue with eschar
4. fistula to arteries and veins
Documentation of a wound should include what information? (4)
1. assessment of wound
2. describe surrounding skin
3. describe nursing interventions (solutions/dressings)
4. pressure-lowering devices
What are examples of documentation locations where you may list specific information regarding a pressure ulcer, including it's treatment, assessment, etc.?
Flow sheet, nurses notes, hospital forms, Nursing plan of care
When assessing a wound, what information should you list? (5)
1. length, width, and depth
2. exudate
3. odor
4. description of tissue in wound bed
5. estimate of the percentage of viable and nonviable tissue
What are the 5 essential components of nursing care? (for pressure ulcer treatment, but applicable to many areas of nursing care)
1. documentation
2. consistency
3. correct use of materials
4. strict adherence to technique
5. continuous evaluation