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23 Cards in this Set

  • Front
  • Back
pressure ulcer
sore caused by prolonged pressure against skin

result of tissue anoxia

begin to develop within 20 to 40 minutes of unrelieved pressure on skin
skin & subq tissue remain stationary - fat, muscle, & bone shift in direction of body movement - deep tissue damage

occurs when patient slides down in bed when head of bed is raised or when pt is pulled/repositioned w/o being lifted off sheets
three-color pressure ulcer classification system
Black: wound indicates necrosis

Yellow: wound has exudate & is infected

Red: wound is pink/red and is in healing stage
What is the pressure level that closes capillaries in healthy people?
25 to 32 mm Hg
Risk factors for developing pressure ulcers include (6 listed) . . .
1) immobility
2) impaired circulation
3) impaired sensory perception
4) elderly
5) very thin
6) obesity
Possible interventions for prevention of pressure ulcers include (13 listed) . . .
1) daily assessment
2) mild soap & water daily and prn
3) pat wet skin dry
4) moisturizers
5) NO massage to reddened areas
6) shift weight q15 min
7) highest level of mobility maintained
8) resposition pt in chair every hour
9) turn pt on bedrest q12h
10) heels off bed
11) pad/protect bony areas
12) use lift sheet to move
13) adequate nutrition & hydration
The most common sites for pressure ulcers are the (6 listed) . . .

Lateral malleoli
Greater trochanters
Ischial tuberosities
All pressure ulcers are considered to be 1_____ with 2_____.
1) colonized

2) bacteria
1_____ 1_____ and 2_____ & 3_____ tests may be done to identify the causative organism in suspected infection sites.
1) Swab cultures

2) culture

3) sensitivity
Treatment for pressure ulcers involves (4 steps) . . .
1) removing all pressure

2) cleanse w/30 mL syringe & 18 gauge needle - irrigate w/250 mL ns

3) debride

4) provide clean, moist environment/dressing
Commonly used dressing materials for pressure ulcers include (6) . . .
1) hydrogel dressings

2) polyurethane films

3) hydrocolloid wafers

4) biologic dressings

5) alginates

6) cotton gauze
The stages of pressure ulcer severity (based on depth of tissue destroyed) are . . .
Stage I: skin intact - red - does not blanch

Stage II: break in skin - partial thickness skin loss -appears as abrasion/crater/blister

Stage III: full thickness skin loss - deep crater - may have eschar

Stage IV: damage to muscle, bone, or support structures
purulent fluid
fluid containing pus (infected)

creamy yellow = Staph
beige = Proteus
green/blue = Pseudomonas
brown = Bacteroides
inflammation of skin

S/S: itching - redness - skin lesions - crusts - fissures - macules - papules - vesicles - pustules
What are some possible causes of dermatitis? (3)
1) exposure to allergens/irritants

2) heredity

3) emotional stress
What are the three, mostly-chronic types of dermatitis?
1) contact: caused by contact w/irritant or allergen

2) atopic: inherited - may be assoc. w/respiratory allergies or asthma

3) seborrheic: inflammatory dx - can have scaling or seborrhea
excessive production of sebaceous secretions

found in areas w/abundant sebaceous glands (scalp-face-axilla-genitocrural areas)
Two potential complications of dermatitis are 1_____ and 2_____.
1) infection

2) sepsis
Diagnosis of dermatitis is usually based on 1_____, 2_____, and 3_____ 3_____. If infection is suspected, 4_____ of the lesions may be ordered to identify the infecting agent.
1) history

2) symptoms

3) clinical findings

4) cultures
The basic treatment goals for dermatitis are (7 listed) . . .
1) control itching

2) alleviate discomfort/pain

3) decrease inflammation

4) control/prevent crust formation & oozing

5) prevent infection

6) prevent added damage to skin

7) heal skin as much as possible
Itching and discomfort can be somewhat relieved by 1_____, 2_____, and 3_____ medications as ordered. Colloidal oatmeal preparations added to baths can also help relieve some of the 4_____.
1) antihistamines

2) analgesics

3) antipruritic

4) pruritus
What can be used to suppress inflammation caused by dermatitis?
(topical - intralesional - systemic)
What two methods can be used to help control oozing and prevent further crust formation associated with dermatitis?
tub baths

wet dressings