Ch 39

Front 1

what is a pressure ulcer

Back 1

a locolized injury to the skin or underlying tissue usually over the bony prominence, as a result of pressure

Front 2

who is at risk for pressure ulcers

Back 2

decrease circulation, inadequate nutrition, decrease sensory perception, immobility, infection, decreased immune system, decrease arterial pressure

Front 3

describe the structure and function of the skin

Back 3

epidermis, dermis, subcutaneous tissue and the function is protection, thermoregulation, sensation, metabolism(vit d), and communication

Front 4

factors that affect the integumentary function

Back 4

circulation, nutrition, condition of the epidermis, allergy, infections,, abnormal growth rate, systemic disease, and trauma

Front 5

the Braden Scale is based on what 6 things

Back 5

sensory, moisture, activity, shear and friction, nutrition, and mobility.

Front 6

what are the Braden Scale Scores

Back 6

1= Highly impaired
3 or 4= moderate to low impairment
total points possible= 23
Risk predicting scores 16 or less

Front 7

How would you describe stage 1 pressure ulcer

Back 7

intacted,can see redness, no break in skin, non-blanchable, area may be warmer or cooler, soft, firm, painful

Front 8

Describe stage II

Back 8

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

Front 9

Describe stage III

Back 9

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

Front 10

Describel Stage IV

Back 10

See bone, tendon, muscle. slough, eschar may be present on some parts of the wound bed, often include undermining and tunneling.

Front 11

what are the phases of wound healing

Back 11

hemostasis, inflammation, proliferative and maturaiton

Front 12

hemostasis phase

Back 12

the onset of vasoconstriction,platelet aggregation and clot formation

Front 13

inflammation phase

Back 13

lasts up to 3 days, it is marked by vasodilation and phagocytosis as the body works to clean the wound

Front 14

proliferative phase

Back 14

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

Front 15

maturation phase

Back 15

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

Front 16

How long before the tissue reaches its maximum strength

Back 16

10 to 12 weeks, but complete healing only 70 to 80 %

Front 17

What are the three types of wound healing

Back 17

Primary intention, secondary intention and Tertiary intention

Front 18

describe primary intention

Back 18

wounds with minimal tissue loss. Ex. clean surgical incisions or shallow sutured wounds. the edges of the wounds are lightly pulled together.

Front 19

describe secondary intention healing

Back 19

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

Front 20

decribe tertiay intention

Back 20

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

Front 21

wound assessment includes

Back 21

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

Front 22

Deccribe serous fluid

Back 22

pale yellow, watery, and like the fluid from a blister

Front 23

Describe sanguineos

Back 23

drainage is bloody, as from acute laceration, bright red

Front 24

Describe serosanguineos

Back 24

drainage is pale pink yellow, thin, and contains plasma and red cells, pinkish

Front 25

Describe purulent

Back 25

drainage contains white cells and microorganisms and occures when infection is present, thick opaque, white yellowish look

Front 26

Silver dressings

Back 26

helps with bacterial infected wounds