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27 Cards in this Set

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pressure
the force that is applied vertically or perpendicular to the surface of the skin. Pressure compresses underlying tissue and small blood vessels hindering blood flow and nutrient supply. Tissues become ischemic and are damaged or die.
shear
when one layer of tissue slides horizontally over another, deforming adipose and muscle tissue, and disrupting blood flow
sites at risk for pressure ulcers
bony prominences
how to stage decubiti
The pressure ulcer should be staged according to the maximum anatomic depth of tissue damage
Stage I
The pressure ulcer should be staged according to the maximum anatomic depth of tissue damage
Stage II
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage II pressure ulcers may also present as an intact or open/ruptured serum-filled or serosangineous-filled blister.
Stage III
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. Stage III pressure ulcers may include undermining and tunneling.
Stage IV
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. These ulcers often include undermining and tunneling.
friction
rubbing of skin against rough surface
What are sources of moisture that can impact skin integrity?
Incontinence, diaphoresis, wound exudate, spilled water or other fluids
What are some intrinsic factors in the development of pressure ulcers?
Immobility, impaired sensation, malnourishment, aging, fever, low blood pressure.
What are some extrinsic factors in the development of pressure ulcers?
Friction, shearing, moisture
primary intention wound healing
wound is mechanically closed (sutures, staples, or surgical glue
secondary intention wound healing:
wound heals from the bottom up through granulation
intention wound healing
: the wound begins to heal by secondary intention, and once is partially granulated is then surgically closed with sutures
evisceration
evisceration is dehiscence PLUS internal body contents coming out through the dehisced wound and being on the outside of the body.
Dehiscence
the opening up of a sutured or stapled wound
appearance of serous drainage
Clear
What causes serous drainage?
Serum leaking from capillaries of a clean wound
appearance of sanguineous drainage
Bloody, red
cause of sanguineous drainage
Bleeding, from damage to capillaries; seen in deep wounds or highly vascular tissue
appearance of serosanguineous drainage
Bleeding, from damage to capillaries; seen in deep wounds or highly vascular tissue
cause of serosanguineous drainage
Bleeding, from damage to capillaries; seen in deep wounds or highly vascular tissue
appearance of purulent drainage
Pus-like: yellow, green, brown, or blue
cause of purulent drainage
indicates infection
appearance of purosanguineous drainage
Blood and pus
cause of purosanguineous drainage
Pus in an infected wound that also has ruptured capillaries