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23 Cards in this Set
- Front
- Back
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pressure ulcer
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sore caused by prolonged pressure against skin
result of tissue anoxia begin to develop within 20 to 40 minutes of unrelieved pressure on skin |
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shearing
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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 |
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three-color pressure ulcer classification system
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Black: wound indicates necrosis
Yellow: wound has exudate & is infected Red: wound is pink/red and is in healing stage |
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What is the pressure level that closes capillaries in healthy people?
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25 to 32 mm Hg
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Risk factors for developing pressure ulcers include (6 listed) . . .
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1) immobility
2) impaired circulation 3) impaired sensory perception 4) elderly 5) very thin 6) obesity |
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Possible interventions for prevention of pressure ulcers include (13 listed) . . .
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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 |
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The most common sites for pressure ulcers are the (6 listed) . . .
SHELGI |
Sacrum
Heels Elbows Lateral malleoli Greater trochanters Ischial tuberosities |
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All pressure ulcers are considered to be 1_____ with 2_____.
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1) colonized
2) bacteria |
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1_____ 1_____ and 2_____ & 3_____ tests may be done to identify the causative organism in suspected infection sites.
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1) Swab cultures
2) culture 3) sensitivity |
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Treatment for pressure ulcers involves (4 steps) . . .
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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 |
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Commonly used dressing materials for pressure ulcers include (6) . . .
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1) hydrogel dressings
2) polyurethane films 3) hydrocolloid wafers 4) biologic dressings 5) alginates 6) cotton gauze |
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The stages of pressure ulcer severity (based on depth of tissue destroyed) are . . .
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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 |
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purulent fluid
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fluid containing pus (infected)
creamy yellow = Staph beige = Proteus green/blue = Pseudomonas brown = Bacteroides |
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dermatitis
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inflammation of skin
S/S: itching - redness - skin lesions - crusts - fissures - macules - papules - vesicles - pustules |
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What are some possible causes of dermatitis? (3)
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1) exposure to allergens/irritants
2) heredity 3) emotional stress |
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What are the three, mostly-chronic types of dermatitis?
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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 |
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seborrhea
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excessive production of sebaceous secretions
found in areas w/abundant sebaceous glands (scalp-face-axilla-genitocrural areas) |
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Two potential complications of dermatitis are 1_____ and 2_____.
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1) infection
2) sepsis |
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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.
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1) history
2) symptoms 3) clinical findings 4) cultures |
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The basic treatment goals for dermatitis are (7 listed) . . .
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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 |
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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_____.
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1) antihistamines
2) analgesics 3) antipruritic 4) pruritus |
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What can be used to suppress inflammation caused by dermatitis?
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steroids
(topical - intralesional - systemic) |
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What two methods can be used to help control oozing and prevent further crust formation associated with dermatitis?
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tub baths
wet dressings |
