Ch 48_ Skin Integrity and Wound Care Flashcards
What is a pressure ulcer?
A local injury to the skin over a bony prominence due to pressure and other factors
How does pressure result in an ulcer forming?
• If pressure over a capillary exceeds normal capillary pressure and the vessel is occluded (obstructed) for a prolonged time, tissue ischemia (shortage of blood supply/O2) occurs which can cause tissue death.
What is “blanching”
Normal red tones of skin are abscent when area is pressed and released.
What is “non-blanching”?
When an reddish area is pressed and released and no blanching occurs. Indicative of an ulcer/pressure issue.
What are the 6 risk factors for pressure ulcer development?
- Impaired sensory perception - unable to feel pressure or pain 2. Alterations in LOC - Confused and unable to verbalize 3. Impaired mobility - unable to change position independently 4. Shear (sliding of skin) 5. Friction (dragging of skin) 6. Moisture
How many stages are there in the classification of pressure ulcers?
4 only
Describe a Stage 1 pressure ulcer.
Intact skin with non-blanchable redness
Describe a Stage 2 pressure ulcer.
Partial-thickness skin loss involving epidermis, dermis, or both
Describe a Stage 3 pressure ulcer.
Full-thickness tissue loss with visible fat
Describe a Stage 4 pressure ulcer.
Full-thickness tissue loss with exposed bone, muscle, or tendon
What is the term for an ulcer that defies clear indentification of the 4 stages of pressure ulcer classification?
Non-stageable
Define unstabeable ulcer.
Pressure ulcer with full-thickness tissue loss in which the depth is obscured by slough and/or eschar in the wound bed.
What are the colors of slough?
• yellow • tan • gray • green • brown
What are the colors of eschar?
• tan • brown • black
Define a suspected deep tissue injury
A purple or marron localized area of discolored intact skin or blood-filled blister caused by damage to underlying tissue from pressure and/or shear.
Wound healing occurs by _____ or _____ intention.
Primary, secondary
When checking on wound healing, what are the items we are assessing? REEDA
• Redness • Ekymosis • Edema • Drainage • Approximation
Define the primary intention healing process
• This occurs when the would edges are approximated • ex. surgical incision is sewn up and winds up with minimal to no scarring
Define the secondary intention healing process
Secondary intention occurs when the would heals with non-approximated edges and leaves a scar
A surgical incision heals by _____ intention.
primary
A burn, pressure ulcer, or severe laceration heals by _____ intention.
secondary
Describe tertiary intention.
• occurs when the wound is left open for several days • while open, it is observed for signs of infection • closure is delayed until infection is resolved
What are the 4 types of wound drainage?
- Serous 2. Sanguineous 3. Serosanguineous 4. Purulent
Describe Serous wound drainage.
• This type of drainage is plasma that’s thin, clear and watery • During the inflammatory stage, a small amount of this bloody leakage is natural. • When this type of exudate occurs during other wound healing stages, it may be an indicator that the wound bed has undergone trauma, such as during dressing changes, which can hinder healing.
