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39 Cards in this Set

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A localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure, shear, or friction.

pressure ulcer

True/False
Pathogenesis for pressure ulcers includes:
-pressure intensity
-blanching
-pressure duration
-tissue tolerance

True

What are some risk factors for development of a pressure ulcer?
-impaired sensory perception
-alterations in LOC
-impaired mobility
-shear
-friction
-moisture
True/False
A surgical incision can be staged
false
What stage of pressure ulcer is this?
-Intact skin with nonblanchable redness
Stage 1
What stage of pressure ulcer is this?
-Full thickness tissue loss with exposed bone, muscle or tendon.
Stage 4
What stage of pressure ulcer is this?
-Full thickness tissue loss with visible fat
Stage 3
What stage of pressure ulcer is this?
-Partial thickness skin loss involving epidermis, dermis, or both
Stage 2
True/False
You can stage black necrotic tissue.
False
True/False
Granulated tissue is pink and healthy looking.
True

True/False
Primary intention is the primary union of the edges of a wound, progressing to complete scar formation without granulation.

True

True/False
In reference to wound healing methods Secondary Intention refers to a wound in which the edges are approximated

False

Edges are not approximated which makes measurement more difficult. Also the granulated tissue closes the wound from the inside out

True/False
In reference to wound healing, Tertiary Intention refers to a wound being left open for several days and closed at a later time.

True
Lots of drainage would cause damage to the wound if it were closed prematurely
True/False
Length, width and depth are measured in cm
True
True/False
A hemorrhagic sanguineous appearance of the wound indicated severe damage to the capillaries
True
True/False
A serosangiuneous appearance is clear and blood tinged drainage
True
True/False
A purosanguineous appearance presents as pus and blood
True

What are some factors influencing ulcer formation and wound healing?

-nutrition
-tissue perfusion
-infection
-age
-psychosocial impact if wounds

True/False
The hypodermis decreases in size with age. So older clients have little subcutaneous tissue padding over bony prominences.
True

The _____ scale uses six risk factors to determine skin integrity. Total range is from 6-23, where a lower score indicates a high risk for pressure ulcers.

Braden

The risk factors include:
-sensory perception
-moisture
-activity
-mobility
-nutrition
-friction and shear

What are some nursing diagnosis related to skin integrity and wound care?

-risk for impaired skin integrity
-impaired skin integrity
-impaired tissue integrity
-risk for infection
-pain

Some types of implementation for skin integrity and wound care could be?

-using topical skin care
-positioning
-use of support surfaces

______ is the removal of necrotic nonviable tissue.
debridement

_____ occurs when pressure is applied to capillaries and occludes sufficient oxygen and perfusion

Tissue ischemia

____occurs when the normal red tones of the light skinned client are absent upon pressure

Blanching
Blanching is not present in a dark skinned client. The skin will instead look purple in color or darker than surrounding skin.

True/False
Patients who are restless or have uncontrollable movements such as spastic conditions are at risk for friction induced wounds

True
Shear occurs more from force exerted parallel to skin resulting from gravity and resistance pushing down on the body. It effects skin deeper than just the epidermis as friction does.

Black or brown necrotic tissue is called ____. A thick layer of dead, dry tissue that covers a pressure ulcler or thermal burn.

eschar
____ is the final stage of healing and can take up to a year
Remodeling
Stages of wound healing are:
1) Inflammatory
2) Proliferative
3) Remodeling
The _____ stage of wound healing occurs when granulation tissue begins to cover the wound and epithelialization occurs.
proliferative
____ describes total separation of wound layers, and the protrusion of visceral organs
Evisceration

______ is the partial of total separation of wound layers, revealing underlying tissues.

Dehiscence

_____ protects the wound from surface contamination
Hydrocolloid
_____ maintains a moist surface to support healing
Hydrogel
A ____ uses negative pressure to support healing
wound V.A.C.
vacume assisted closure
True/False
Pressure ulcers usually develop within the first two weeks of hospitalization
True
True/False
At least 1500 kcal/day are required for nutritional maintenance of a post operative individual
True
Heat should only be applied for ____ or less, because it will start to reduce blood flow by causing vasoconstriction.
1 hour or less
The application of a ____ compress will initially diminish swelling and pain. Prolonged exposure results in reflux vasodilation.
cold