Wound Care ATI 55 Flashcards

pressure ulcer
Terms Definitions
Wounds are a result of?
injury to the skin
What is a pressure ulcer?
a specific type of tissue injury caused by unreleieved pressure that results in ischemia and damage to the underlying tissue
Suspected deep tissue injury show?
discolored but intact skin
What is stage 1 pressure ulcer?
intact skin, non blanchable redness, typically over a bony prominence, tissue swollen, with darker skin the site appears blue or purple
What is stage 2 pressure ulcer?
partial thickness skin loss, involving epidermis and dermis, ulcer visible, may appear as an abrasion, blister, or shallow crater, edema present, possible drainage
What is stage 3 pressure ulcer?
full thickness tissue loss with damage to subQ tissue, deep crater without undermining of adjacent tissue, no muslce or bone exposed, drainage and infection are common
What is stage 4 pressure ulcer?
full thickness tissue loss with damage to sub Q tissue, damage to muscle, bone, and supporting structures, deep pockets of tunneling, infection, eschar, and slough
What is an unstagable ulcer?
ulcer whose stage cannot be determined because eschar or slough obscures the wound
What do the first 3 days of healing consist of?
inflammatory stage, control bleeding, deliver oxygen, WBC and nutrients to the area
What is the proliferative stage?
3-24 days of wound healing
What happens during the proliferative stage?
replace lost tissue, contracting wound edges, resurfacing of new epithelial cells
What does the maturation or remodeling stage involve?
the strengthening of the collagen scar an the restoration of a more normal appearance. (can take 1 year)
What is the characteristics of primary intention healing?
little or no tissue loss, edges are approximated (surgical incision)
What type of wound goes with primary intention healing?
heals fast, low risk infection, no scarring
What are the characteristics of secondary intention healing?
loss of tissue, wound edges widely separated (pressure ulcer, stab wound)
What type of wound type goes with secondary intention healing?
longer healing time, increase risk of infection, and scarring
What are the characterisitics of tertiary intention healing?
widely separated, deep, spontaneous opening of previously closed wound, risk of infection
What is the wound types that goes with terieary intention of healing?
extensive drainage and tissue debris, closed later, long healing time
What are factors that affect wound healing?
age, wellness, immune function, meds, nutrition
Increased age delays healing because of?
loss of skin tugor, skin fragility, decreased peripheral circulation, slower tissue regeneration, decreased absorption of nutrients, decrease collagen
Fatty tissue lacks?
blood supply
smoking impairs?
oxygenation and clotting
Inflammation is a?
localized protective response triggered by injury or destruction of tissue
What are principles of wound care?
Assess, clean, protect
What does a red wound indicate?
healthy regeneration of tissue
What does a yellow wound indiate?
presence of purulent drainage
What does black wound indicate?
presence of eschar that stops healing process, must be removed
Drainage is?
a normal result of the healing process
How is the character of the drainage noted?
consistency, color, and odor
What is serous drainage?
portion of the blood that is watery and clear
What is sangineous drainage?
serum and RBC, thick and reddish
What is serosangineous drainage?
serum and blood, blood streaked
What is purulent drainage?
result of infection, thick and contain WBC, tiss debris, and bacteria, may have foul odor
What should a pt have during wound healing?
hydration and protein
What are preferred cleansing agents for wounds?
isotonic
What do woven gauze do?
absorbs exudate from the wound
What does nonadherent material do?
does not adhere to wound bed
What does self adhesive transperent film do?
is a temporary "second skin", for small superficial wounds
What is hydrocolloid?
occlusive dressing that swells in the presence of exudate
What is hydrogel used for?
infected deep wounds, provides moist wound bed
What is dehiscence?
partial or toatal rupture of a sutured wound, usually with separation of underlying skin layers
What is evisceration?
profusion of organs through opening
What are s/s of dehiscence?
increase in flow of fluid, straining, client report popping
What is the primary focus for prevention of pressure ulcers?
relieve pressure, and provide hydration and nutrition
How do you prevent pressure ulcers?
clean, dry skin and wrinkle free linens
What is shearing force?
sliding in bed
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