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wound care lesson2
Terms in this set (24)
ABI stands for?
ankle brachial index
What is the ankle-brachial index (ABI)?
the systolic pressure of the ankle, divided by the systolic pressure at the arm.
what has ABI been shown in diagnosing which disease?
peripheral arterial disease (PAD)
what is a normal systolic reading?
less than 10 mmHg
how is ABI measured?
measuring the systolic blood pressure from both brachial arteries & from both the dorsalis pedis & posterior tibial arteries after the pt has been at rest in supine for 10 minutes.
what is the difference between an ulcer & a pressure injury?
pressure injury could be prevented & caused by the PT. Ulcer happens without our attention.
what form of medication could increase the cause of pressure injuries?
etiology of a pressure injury
- underlying tissue compressing the soft tissue between the surface skin & bone.
- when pressure exceeds the inter-capillary blood flow pressure, flow will become obstructed & localized ischemia occurs - necrosis to follow.
how many stages are there in staging a pressure injury?
T/F: once a wound is a certain high-level stage, it is always that stage.
if a pt develops a stage 4 pressure injury that is now healed & is more of stage 2, what stage is this?
they have a stage 4 pressure injury presenting as a stage 1
classification of a stage 1 pressure injury
non-blanchable erythema of intact skin. only superficial tissue is involved.
press down or skin and it does not turn white
what form of dressing is used for a stage 1?
foam or film
why would a pt. complain of "itchy" during a stage 1?
inflammatory response, all the -ines are rushing to the area.
what are the characteristics of a stage 2 pressure injury?
superficial injury that presents most often as a small crater or blister - may be shallow with a reddish base.
would a partial-thickness would that involves the epidermis or dermis be stage 1 or stage 2?
what are the goals of treating a stage 2?
cover, protect & clean the area
What are the characteristics of a stage 3?
deep tissue insult that presents as a deep crater & may have tunneling or undermining. Full thickness wound involving the epidermis, dermis & subcutaneous tissue.
what is often present in a stage 3?
slough & necrotic tissue
at what stage do nerves start to die?
a pt. has a pressure injury that presents with a shallow crater & exposed dermal layer, the wound also has 20% eschar. What stage is this?
unstageable bc we do not know what is under the eschar.
what is an eschar?
a pt. has a pressure injury to right lateral malleolus with a clear defined wound edge & exposed bone, there is 40% eschar. What stage is this?
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