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