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39 Cards in this Set
- Front
- Back
- 3rd side (hint)
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
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True/False |
True |
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What are some risk factors for development of a pressure ulcer?
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-impaired sensory perception
-alterations in LOC -impaired mobility -shear -friction -moisture |
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True/False
A surgical incision can be staged |
false
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What stage of pressure ulcer is this?
-Intact skin with nonblanchable redness |
Stage 1
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What stage of pressure ulcer is this?
-Full thickness tissue loss with exposed bone, muscle or tendon. |
Stage 4
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What stage of pressure ulcer is this?
-Full thickness tissue loss with visible fat |
Stage 3
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What stage of pressure ulcer is this?
-Partial thickness skin loss involving epidermis, dermis, or both |
Stage 2
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True/False
You can stage black necrotic tissue. |
False
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True/False
Granulated tissue is pink and healthy looking. |
True
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True/False |
True
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True/False |
False |
Edges are not approximated which makes measurement more difficult. Also the granulated tissue closes the wound from the inside out |
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True/False |
True
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Lots of drainage would cause damage to the wound if it were closed prematurely
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True/False
Length, width and depth are measured in cm |
True
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True/False
A hemorrhagic sanguineous appearance of the wound indicated severe damage to the capillaries |
True
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True/False
A serosangiuneous appearance is clear and blood tinged drainage |
True
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True/False
A purosanguineous appearance presents as pus and blood |
True
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What are some factors influencing ulcer formation and wound healing? |
-nutrition |
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True/False
The hypodermis decreases in size with age. So older clients have little subcutaneous tissue padding over bony prominences. |
True
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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: |
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What are some nursing diagnosis related to skin integrity and wound care?
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-risk for impaired skin integrity |
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Some types of implementation for skin integrity and wound care could be?
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-using topical skin care |
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______ is the removal of necrotic nonviable tissue.
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debridement
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_____ occurs when pressure is applied to capillaries and occludes sufficient oxygen and perfusion |
Tissue ischemia |
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____occurs when the normal red tones of the light skinned client are absent upon pressure |
Blanching
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Blanching is not present in a dark skinned client. The skin will instead look purple in color or darker than surrounding skin.
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True/False |
True
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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.
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Black or brown necrotic tissue is called ____. A thick layer of dead, dry tissue that covers a pressure ulcler or thermal burn. |
eschar
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____ is the final stage of healing and can take up to a year
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Remodeling
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Stages of wound healing are:
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1) Inflammatory
2) Proliferative 3) Remodeling |
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The _____ stage of wound healing occurs when granulation tissue begins to cover the wound and epithelialization occurs.
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proliferative
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____ describes total separation of wound layers, and the protrusion of visceral organs
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Evisceration
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______ is the partial of total separation of wound layers, revealing underlying tissues. |
Dehiscence |
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_____ protects the wound from surface contamination
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Hydrocolloid
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_____ maintains a moist surface to support healing
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Hydrogel
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A ____ uses negative pressure to support healing
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wound V.A.C.
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vacume assisted closure
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True/False
Pressure ulcers usually develop within the first two weeks of hospitalization |
True
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True/False
At least 1500 kcal/day are required for nutritional maintenance of a post operative individual |
True
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Heat should only be applied for ____ or less, because it will start to reduce blood flow by causing vasoconstriction.
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1 hour or less
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The application of a ____ compress will initially diminish swelling and pain. Prolonged exposure results in reflux vasodilation.
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cold
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