• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

Card Range To Study



Play button


Play button




Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

26 Cards in this Set

  • Front
  • Back
what is a pressure ulcer
a locolized injury to the skin or underlying tissue usually over the bony prominence, as a result of pressure
who is at risk for pressure ulcers
decrease circulation, inadequate nutrition, decrease sensory perception, immobility, infection, decreased immune system, decrease arterial pressure
describe the structure and function of the skin
epidermis, dermis, subcutaneous tissue and the function is protection, thermoregulation, sensation, metabolism(vit d), and communication
factors that affect the integumentary function
circulation, nutrition, condition of the epidermis, allergy, infections,, abnormal growth rate, systemic disease, and trauma
the Braden Scale is based on what 6 things
sensory, moisture, activity, shear and friction, nutrition, and mobility.
what are the Braden Scale Scores
1= Highly impaired
3 or 4= moderate to low impairment
total points possible= 23
Risk predicting scores 16 or less
How would you describe stage 1 pressure ulcer
intacted,can see redness, no break in skin, non-blanchable, area may be warmer or cooler, soft, firm, painful
Describe stage II
partial thickness loss of dermis, shallow open ulcer, red-pink wound bed, without slough, may also present as intact or open ruptured serum filled blister
Describe stage III
full thickness tissue loss, subcutneous fat may be visible, but bone tendon, or muscle is not exposed. slough may be present. include undermining and tunneling
Describel Stage IV
See bone, tendon, muscle. slough, eschar may be present on some parts of the wound bed, often include undermining and tunneling.
what are the phases of wound healing
hemostasis, inflammation, proliferative and maturaiton
hemostasis phase
the onset of vasoconstriction,platelet aggregation and clot formation
inflammation phase
lasts up to 3 days, it is marked by vasodilation and phagocytosis as the body works to clean the wound
proliferative phase
the epidermis cells, which appear pink reproduce and migrate across the surface of the wound, called epithelialization , in full thickness wounds it begins with granulation tissue
maturation phase
begins 3 weeks after injury and may last 3 yrs. the number of fibroblast decreases, collagen synthesis stabilizes and collagen fibrils become increasingly organized resulting in greater tensile strength of the wound
How long before the tissue reaches its maximum strength
10 to 12 weeks, but complete healing only 70 to 80 %
What are the three types of wound healing
Primary intention, secondary intention and Tertiary intention
describe primary intention
wounds with minimal tissue loss. Ex. clean surgical incisions or shallow sutured wounds. the edges of the wounds are lightly pulled together.
describe secondary intention healing
full-thickness tissue loss,deep lacerations, burns and pressure ulcers have edges that do not readily approximate. the open wound gradually fills with granulation tissue. eventually epithelial cells migrate across the granulation base, completing the cycle. wound is open for a longer time, it may become colonized with microorganism that may lead to infection
decribe tertiay intention
it occurs when a delay ensues between injury and wound closure, known as delayed primary closure. happens when a deep wound is not sutured immediately or is purposely left open until there is no sign of infeciton then closed with sutures
wound assessment includes
wound type: surgical vs nonsurgical or acute vs chronic
Location, size,
classificaiton: partial vs full thickness, stage if a pressure ulcer, wound base=healthy, pink, red, non viable, viable, necrotic tissue, brown to black
wound drainage=color amt,consistency and odor
Deccribe serous fluid
pale yellow, watery, and like the fluid from a blister
Describe sanguineos
drainage is bloody, as from acute laceration, bright red
Describe serosanguineos
drainage is pale pink yellow, thin, and contains plasma and red cells, pinkish
Describe purulent
drainage contains white cells and microorganisms and occures when infection is present, thick opaque, white yellowish look
Silver dressings
helps with bacterial infected wounds