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103 Cards in this Set

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Term used to describle impaired skin integrity
Pressure Ulcers
When does tissue ischemia occur?
When capillary blood flow is obstructed
Is reactive blanching hyperemia good or bad?
good
Reactive Blanching Hyperemia
blood vessels dilate in the area of injry and prevent tissue trauma
Non-blanching reactive hyperemia
indicated tissue damage
Is non-blanching reactive hyperemia good or bad?
bad
Shear
trauma to skin when the skin stays in place, and bones move
What happens to skin with friction?
top layer removed, irritated, abrasion
What are some risk areas for fricton?
heels and elbows
What is friction?
when two surfaces rub together
What reduces resistance to shear and friction
moisture
how much should you increase protein to help promote wound healing?
2-4x's
What can protein deficiency lead too?
edema
When do you have a negative nitrogen balance
nitrogen is excreted from protein breakdown and exceeds protein intake
What happens when fluids shift from extracellular volume to tissues
edema
What are the serum levels when a person has hypoalbuminemia?
<3g/100mL
How does tissue increase risk for ischemic injury?
fever increases metabolic needs of body, creating more hypoxic tissue
What age group is at the highest risk for skin breakdown?
older adults
What are pressure ulcers caused by?
pressure exerted against skin surfaces
What factors alter the ability of skin to respond to pressure?
shear, friction, moisture, nutrition, infection, age
Stage 1
observable change in skin, changes temp, sensation, and feeling/consistency
Stage 2
partial-thickness skin loss
What does the ulcer look like in Stage 2?
superficial
Stage 3
full thickness skin loss involving sq tissue
Does a stage 3 go through fascia?
no
Does a stage 3 have necrosis?
maybe
Stage 4
full thickness skin loss with tissue necrosis, damage to bone and muscle
What can impair the staging of ulcers?
necrosis
Two types of healing
primary intention, secondary intention
How does a wound heal when doing so by secondary intention?
granulation
What happens when bacteria invades a tissue?
infection
Dehiscence
partial or total separation of skin and tissue
When would dehiscence normally happen?
3-11 days PO
What is evisceration?
would layers separate below the fascial layer
Fistula
abnormal opening between two organs or between organ and outside of the body
What structures do you assess when assessing for pressure ulcers?
skin, underlying tissue, muscle
Name for pressure ulcer scale?
Braden
Serous
clear drainage
sanguineous
bloody drainage
serosanguineous
bloody streaked, watery drainage
purulent
yellow, green think drainage
Do dressings influence wound healing?
yes
Most common type of dressing?
gause
wet to dry dressing
gauze soaked in NS, covered w/dry gauze
What type of dressing is used to debride wounds?
wet to dry
What type of dressing traps moisture over wound bed?
transparent film
What used negative pressure to promote healing
wound vac
Which type of dressing is a geling agent
hydrocolloid
What does a hydrocolloid dressing do?
protects the wounds from surface contamination
What type of dressing maintains a moist environment to support healing
hydrogel
What dressing is made from seaweed?
calcium alginate
What type of dressings are used for heavily draining wounds?
calcium alginate
What do you need to know when changing a dressing?
type, drain placement and equipment needed
What is the best cleansing agent for cleansing wounds?
normal saline
What does irrigation do?
removes exudate and debris
What are drainage evacuations?
portable units that exert constant, low-pressure vacuum to remove and collect drainage
What is the easiest way treat ulcers?
prevent them
what is it called when an area blanches with fingertip pressure?
reactive blanching hyperemia
what is it called when an area does not change color when pushed?
nonblanching reactive hyperemia
Doing what action might possible cause shear?
moving a pt up in bed
What layer of skin is friction injury contained to?
epidermis
Cachexia
generalized ill health and malnutrition
What is cachexia marked by?
weakness and emaciation
In what type of healing do edges of wounds approximate?
primary intention
Delayed primary closure
closure of deep tissue layers and SQ fat and skin are left open
Two mechanisms of wound healing.
partial and full thickness repair
when is Partial thickness repair needed?
when there is loss of the epidermis and/or part of the dermis
When is full thickness repair needed?
loss of epidermis, dermis, and possible sq, bone and muscle
Type of wound repair that includes resurfacing wound with new epidermal tissue
partial-thickness
When does a scab form?
when exudate that bring WBC's to area drys
Epidermal repair
when epidermal cells migrate across wound
Differentiation
epidermis thickens, anchors to adjacent cells and resumes normal function
Inflammation phase
control of bleeding, clean wound environment
What causes coagulation and vasoconstriction to stop bleeding?
platelets
Phases of full thickness repair?
inflammation, proliferative, remodeling
key events in proliferative phase
make new tissue, epithelialization, contraction
What forms to provide O2 and nutrients for new tissue and contributes to the synthesis of collagen
new capillary networks
Epithelialization
epithelial cells migrate to cover wound
Remodeling phase
production of scar
How long does the remodeling phase last
one year
Hemorrhage
excessive bleeding
hemostasis
cessation of bleeding by vasoconstriction and coagulation
symptoms of internal bleeding
hypovolemic shock and swelling
hematoma
collection of clotted blood under tissues
When should you be alert for dehiscence
serosanguineous drainage
6 factors of braden scale
sensory perception, moisture, activity, mobility, nutrition, friction, shear
abrasion
loss of dermis
laceration
damage to dermis, and epidermis, torn, jagged wound
wound culture
test to see what microbes are in a wound
How often should skin assessment be done?
daily
should you massage reddened areas?
no
debridement
method for removal of necrotic tissue
maceration
breakdown of skin from prolonged exposure to moisture
What technique do you use when changing a dressing?
aseptic
What is the most likely anchor to cause skin irritation
adhesive tape
What solutions should not be used to clean a wound?
betadine, hydrogen peroxide, acetic acid
What part of the would to you begin with when cleaning?
begin at least contaminated to most contaminated
drainage evacuator
protable units that connect to tubular drains that exert a low pressure
binder
bandages made of large pieces of material to fit a specific body part
compress
piece of gauze dressing moistened in warmed solution
warm soak
immersion of body part in warmed solution
what does a warm soak promote?
circulation, lessens edema, increases muscle relaxation, can apply medicated solution
Sitz bath
bath in which only pelvic area is submerged