| Term | Definition |
|---|
| Poor skin turgur is manifested by | dehydration |
| Skin should be | warm and dry |
| Skin assessment includes | color, texture, temp, turgur, moisture, sensation, vascularity, presence of lesions... |
| two types of wounds | intentional and unintentional |
| Intentional wounds | wound occurs during therapy |
| unintentional wounds occur | accidentally. |
| 4 ways that wounds are classified according to how they are acquired... | Clean, clean-contaminated, Contaminated, or dirty or infected.. |
| Other names for pressure ulcers... | decubitous ulcer, pressure sores, or bedsores |
| Pressure ulcers are | the most common type of skin disruption and most preventable |
| This is due to localized ischemia (cut off of blood supply) | cause of pressure ulcers |
| Reactive hyperemia | is when skin becomes bright red. |
| after pressure ulcer developement...if redness disappears...? | no damage is done. |
| after pressure ulcer developement...if redness remains...? | damage has been done. |
| Nurse can press down on potential pressure ulcer...if it stays red (doesnt turn white for a moment)... | You know you have a Stage 1 pressure ulcer. |
| Friction is rubbing how many ways? | 1 way |
| Shearing is rubbing how many ways? | 2 ways |
| Most common sights for pressure ulcers | sacrum, coccys, calcaneous (heals) |
| Way to measure skin risk | Braden Scale |
| What score is high risk for Braden Scale? | less than 18 is high risk |
| Good score for braden scale | 23 or higher |
| Five layers to be aware of when considering pressure ulcers | Epidermis, Dermis, Sub Q, Muscle tissue, and bone |
| Charactoristics of Stage 1 P.U. | affects the epidermis, and non blanchable skin |
| Stage 2 P.U. details | Affects epidermis and dermis, partial thickness skin loss, abrasion blister and shallow crater |
| Stage 3 p.u. details | tissue necrosis of Sub Q layer, full thickness skin loss, deep crater |
| Treatment of Stage 2 | Saline and occlusive dressing |
| Treatment of stage 3 | damp to damp dressing and surgical intervention (keep it clean and moist) |
| Stage 4 pressure ulcer details | tissue necrosis with damage to muscle, bone,, tendons, or joint capsules, full thinkness skin loss, cover with non-adherent dressing |
| Treatment for Stage 4 PU | Change dressing every 8-12 hours AND may require skin grafts |
| Another name for drainage | Exudate |
| presence of abnormal pathways includes: | sinus tract, tunneling, or undermining (caves) |
| you can clean wounds with gentle ______? | Irrigation |
| Debribement can include using... | Sharps or enzymes (chemicals) |
| The three phases of wound healing | inflammation, proliferation, and maturation |
| inflammatory phase lasts... | 3-6 days |
| during the inflammatory phase...what is deposited? | Fibrin |
| hemostasis= | bleeding stops! during inflammatory stage |
| Proliferative phase | day 3- day 21, fibroblasts synthesize collagen, capillaries grow across wound, granulation tissue forms |
| Maturation phase | day 21- to up to 2 years...collagen is remodeled, would becomes stronger and more like surrounding tissue, and scar formation |
| Fatty tissue has small amount of _______. | circulation. |
| Risk for _____ is greatest in the first 48 hours post op. | Hemorrhage |
| Causes of Hemorrhage: | dislodged clot, slipped suture, or erosion of blood vessel |
| Skin _____ usually occurs 2-7 days after injury. | infection |
| People at risk for dehiscence and evisceration | obese, malnourished, infected wounds, excessive coughing, vomitting, straining |
| dehiscence is | when a wound busts open but nothing (organs) come out |
| eviscerations | when a wound busts open AND organs come out! eww |
| Exudate | fluid and cells that has escaped from the blood vessels during inflammatory process |
| Serous | consists primarily of serum |
| sanguinous | consists of large amts of RBCs |
| Serosangineous | clear and blood tinged drainage |
| purulent | thicker than serous and contains pus! |
| when charting about drainagefrom wound chart: | amt color odor and consistency |
| Types of drains: | penrose, t-tube, jackson-pratt, hemovac, and Wound Vac |
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