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59 Cards in this Set
- Front
- Back
1. Outer layer is dead cells, Basal layer replaces outer layer, 3rd layer protects underlying areas from dehydration and certain chemicals
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Epidermis
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Provides strenght,k mechanical support and protection.
Mostly connective tissue Collagen, blood vessels, nerves |
Dermis
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Easily torn, reduced elasticity, decreased collagen, thinning of muscle, slower wound healing, less pading
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Aging Skin
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Localized unjury to the skin and underlying tissue, usually over a body prominence, as a result of pressure/shear/friction.
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Pressure Ulcer
Pressure sore Decubitus Ulcer Bedsore |
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Decreased mobility
Decreased sensory percept. Fecal or unrinary incont. Poor Nutrition Decreased level of conscious |
Risk for Pressusre Ulcer
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Force exerted parallel to skin from gravity and resistance btw client and surface
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Shear
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force of two surfaces moving across one another.
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Friction
(sheet burn) |
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This softens skin and can come from wound drainage, excessive perspiration, fecal or urine.
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Moisture
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1. Skin Intact, nonblanchable redness
2. Partial skin loss (abrasion, blister, shallow craer) 3.Full thickness tissue loss, visible fat, bone, tendon (not muscle) 4. Full thidkness tissue loss with exposed bone, muscle, tendons |
Pressure Ulcer Classification
1. Stage I 2, Stage II 3. Stage III 4. Stage IV |
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Red, moist tissue composed of new blood vessels; indicates healing
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Granulation Tissue
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Tissue Ischemia
Hyperemia Blanching Tunneling Undermining |
Terminology for pressure ulcers
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Strings substance attached to wound bed
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Slough
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Black or brown necrotic tissue
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Eschar
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Wound drainage, needs to be removed for healing
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Wound Exudate
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Status of skin integrity
Cause of wound Severity of tissue injury Cleanliness Descriptive qualities |
Classifications of wounds
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1.Usually easy to clean and repair.`
2. Healing delayed |
Acute Wounds
Chronic wounds |
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Epithelialization; closed wound
minimal scarring |
Primary intention (healing)
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Wound edges not approximatged
Heals by granulation and epithelialization |
Secondary Intention (healing)
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Wound left open
Closure delayed until infection resolved |
Tertiary intention (healing)
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Shallow with loss of epidermis
Maybe some loss of dermis Heal by regeneration Clean surgical wound |
partial-thickness wounds
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-Inflammatory response
-epithelial proliferation and -migration (cells need moisture to heal quickly) -Reestablshment of the epidermal layers |
healing of partial-thickness wounds
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Extend into dermis
Heal by scar formation (pressure ulcers) |
Full-thickness Wounds
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Inflammatory
Proliferative Remodeling |
Full-thickness woundrepair phases
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Redness, edema, warmth, throbbing
Wound cleaning by WBCs Collagen repair |
Inflammatory Phase
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Granulationtissue fills the wound
Wound contracts Resufacing by epithelialization |
Proliferative Phase
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Collagen scar gets stronger
May take months |
Remodeling Phase
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-Hemmorage
-Infection (inhibits healing) -Dehiscence (Partial or total separation of wound layers) -Evisceration (Protrusion of visceral organs throught the wound opening -Fistula formation(abnormal passage btw two organs - btw organ and outside of body |
Wound Healing Complications
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Occur as an initial spontaneous manifestation a pathological process (insect bite, pressure ulcer)
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Lesion
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Color, location, texture, size, shape, type, grouping, distribution
Exudate Measure height, widtgh depth Palpate |
Lesion Assessment
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If it is wet, dry it.
If it is dry, wet it |
Dressing Lesions
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-Harbors insects or worms
-Good hygene -Careful selection fo sexsual partners |
Infestations
Lice, Scabies, Ticks, Fleas |
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Itching, excoriation, erythema, petechiae
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Lice
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Wavy, brown, threadlike lines on the body - puritis - secondary infections
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Scabies
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-Chronic deep vein insufficiency
-Stasis of blood in the venous systme of the legs -Open, necrotic lesion from lack of O2and nutrients to tissue - Results in prolonged healing - increased risk of infection |
Venous Stasis Ulcer
(occurs around the medial aspect of the ankle) |
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-protein, Vit. C, A, zinc
-Debridement, wet to dry dressings, enzyme ointments -Antibiotics -Protection of site |
Venous Stasis Ulcer Management
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-Prolonged ischemia to the tissues - skin becomes shiny,thin, taut - loss of hair to lower legs - diminished pulses - skin cool - ulcers seen on toes, foot or lateral malleoulus, may become gangrenous
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Aterial leg Ulcer
(dangle leg over side of bed to increas perfusion at night and decrease pain) |
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-Walking - Prevent skin cracking - Keep ulcer clean and dry (sterile dressing) - Not heat or cold - keep hells elevated - Precutaneous transulminal balloon angioplasty ( must restore perfusion for ulcer to heal)
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Management of Aterial Leg Ulcer
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Norton Scale - Physical condition, Mental condition - Activity - Moblitly - Incontinence -
Lower score = higher risk |
Norton Scale Risk Assessment
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Sensory Perception - moisture - acgtivity - moblility - nutrition - friction and shear -
Lower score - higher risk Most common scale used |
Braden Scale
Pressure Ulcers |
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Costs healthcare 2.2 to 3.6 billion a year - increases length of hospital stay from 12 to 30 days -over 1 million affecgted - costs more to treat than to prevent
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Pressure Ulcers
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Nutrition - Infection - Tissue perfusion ( must hqave O2 to heal) - Age -Psychosocial impact of wounds ( body image)
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Factors Influencing Pressure Ulcers formation and wound healing
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Always be on the lookout for _________.
Blanching, abnmormnall reactive hyperemia, induration |
Skin Breakdown
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Superficial - partial-thickness wound
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Abrasion
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Bleeds more depending on the depth and location.(scalp laceration)
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Laceration
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Danger is internal bleeding and infection.
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Puncture Wound
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Amount - Color - Odor -Consistency
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Charactaristics of wound drainage
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Wound Drainage
1. straw colored 2. Bloody Drainage 3.Mix of bloody and straw-colored 4. Yellow with pus |
1. serous
2.sanguineous 3. seroussanguineous 4. Purulent |
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1. Skin blisters
2. Adhesions following surgery 3. nose 4. yellow or green from boils or absess 5.presence of RBCs |
1. serous
2. Fibrinous 3. Catarrhal 4. Purulent 5. Hemorrhagic |
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COACH
Color - Odor - Amount - Consistency - How the clinet tolerates it |
Charting body fluids
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Penrose
Hemovac Jackson-Pratt Wound-VAC |
Drains
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-Risk for infection - Imbalanced nutrition (less) - Acute or chronic pain - imolpaired physical mobility - risk for imparied skin integrity - Ineffective tissue perfusion
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Nursign DX
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Topical skin care, turn every 1-2 hours, support bony surfaces by decreasing pressure with pillows etc.
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Implementation for wounds
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Mechanical
Autolytical Chemical Surgical |
Debridment
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Used after microvascular surgery when venous blood flow is restricted
Used to reduce blood congestion Osteoarthritis (pain relief) - purpura fulminanas - hematomas - systgemic lupus- ear infection |
Leech Therapy
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Freshf water worm with 3 jaws used for suction device.
-sucks 5 - 15 ml f blood over 20 - 45 min. -saliva inhibits thromin and induces vasodilaton |
Leeches
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Gauze -dry or moist
Hydrocolloid - (protects wound from surface contamination) Hydrogel (moist surface) Wound VAC (neg. pressure) |
Dressings
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Removes exudates, use sterile technique with 35 mL syringe and 19 g needle
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Irrigation
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Portable units that exert a safe, constant, low pressure vacuum to remove and collect drainage.
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Drainage Evacuation
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Cleanse wounds with
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Noncytotoxic solution
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