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15 Cards in this Set
- Front
- Back
Risk Factors for Pressure Ulcers
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decreased mobility, decreased sensory perception,
fecal or urinary incontinence, and/or poor nutrition |
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assessment of pressure ulcers
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1. depth of tissue involvement (staging)
2. type and % of tissue in wound bed 3. wound dimensions 4. exudate description 5. condition of surrounding skin |
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staging with nercrotic tissue involves what step
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the depth cant be viewed until necrotic tissue is removed to expose wound base
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Staging levels include:
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Stage I: Nonblanchable Redness of Intact Skin
Stage II: Partial-thickness Skin Loss or Blister Stage III: Full-thickness Skin Loss (Fat Visible) Stage IV: Full-thickness Tissue Loss (Muscle/Bone Visible) |
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Stage I: Nonblanchable Redness of Intact Skin
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Intact skin presents with nonblanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching.
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other names for pressure ulcer
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- pressure sore
- decubitis ulcer - bedsore |
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pressure ulcer
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localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction
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3 pressure related factors that contribute to pressure ulcers are
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(1) pressure intensity,
(2) pressure duration, (3) tissue tolerance. |
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tissue ischemia
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Point at which tissues receive insufficient oxygen and perfusion
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tissue tolerance factors
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1. extrinsic factors - shear, friction, and moisture
2. underlying skin structures (blood vessels, collagen) assist in redistributing pressure. 3. Systemic factors - poor nutrition, increased aging, hydration status, and low blood pressure |
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eschar
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black or brown necrotic tissue - (Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed)
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Granulation tissue
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red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing
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slough
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soft yellow or white tissue - stringy substance attached to wound bed that must be removed for healing
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exudate
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Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes.
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wound exudate should describe the
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the amount, color, consistency, and odor of wound drainage and is part of the wound assessment
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