Chapter 12 exam 1 (b) Flashcards
How many STAGES are there in PRESSURE ULCERS?
(4) Stage 1, 2, 3, 4
-Stage I (minor) to stage IV (severe)
What Stage are these manifestations? Intact skin with non-blanchable redness, Possible indicators—skin temperature, tissue consistency, pain, May appear with red, blue, or purple hues in darker skin tones
Stage 1
Describe a Stage 1 Pressure Ulcer?
Intact skin with non-blanchable redness, Possible indicators—skin temperature, tissue consistency, pain, May appear with red, blue, or purple hues in darker skin tones
Describe a Stage 2 Pressure Ulcer?
- Partial-thickness loss of dermis
- Shallow open ulcer with red pink wound bed
- Presents as an intact or ruptured serum-filled blister
What Stage are these manifestations? Partial-thickness loss of dermis, Shallow open ulcer with red pink wound bed,
Presents as an intact or ruptured serum-filled blister
Stage 2
What Stage are these manifestations?Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia, Presents as a deep crater with possible undermining of adjacent tissue, Depth of ulcer varies by anatomic location.
Stage 3
Describe Stage Pressure 3 Ulcer?
- Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
- Presents as a deep crater with possible undermining of adjacent tissue
- Depth of ulcer varies by anatomic location.
Describe Stage IV Pressure Ulcer?
- Full-thickness loss can extend to muscle, bone, or supporting structures.
- Bone, tendon, or muscle may be visible or palpable.’
- Undermining and tunneling may also occur.
What Stage are these manifestations?
- Full-thickness loss can extend to muscle, bone, or supporting structures.
- Bone, tendon, or muscle may be visible or palpable.’
- Undermining and tunneling may also occur.
Stage 4
Identify risk factors and implement prevention strategies. (3)
- Mobilization
- Frequent repositioning
- Devices
What examples of Prevention (Devices)?
- alternating pressure mattresses
- foam mattresses with adequate stiffness and thickness
- wheelchair cushions
- padded commode seats
- boots (foam, air)
- lift sheets are useful in reducing pressure and shearing force
What are Skin Care Prevention?
- Remove excessive moisture.
- Avoid massage over bony prominences.
- Turn every 1 or 2 hours (with care to avoid shearing).
- Use lift sheets.
- Position with pillows or elbow and heel protectors.
- Use specialty beds.
- Cleanse skin if incontinence occurs.Use pads or briefs that are absorbent.
In PREVENTION what is the CALORIC INTAKE ELEVATED to?
30 to 35 cal/kg/day or 1.25 to 1.50 g protein/kg/day
In PREVENTION what is the CALORIC INTAKE ELEVATED to regarding CAL/KG/DAY? What is the Number?
30 to 35
In PREVENTION what is the CALORIC INTAKE ELEVATED to regarding PROTEIN/KG/DAY? What is the Number?
1.25 - 1.50
Treatment what is COCA?
Document and describe size, stage, location, exudate, infection, pain, and tissue appearance.
What are some Ulcer Care Treatments?
- Keep ulcer bed moist.
- Cleanse with nontoxic solutions.
- Debride.
- Use adhesive membrane, ointment, or wound dressing.
- Verify good nutrition.
- Teach self-care and signs of breakdown.
- Initiate specialty services.
What are some examples of SURGICAL REPAIR in pressure ulcer treatments?
- Skin grafts
- Skin flaps
- Musculocutaneous flaps
- Free flaps
In providing Ambulatory and Home Care, What do you do for the Patient?
Education of both the patient and the caregiver in prevention techniques is extremely important.
What are the 3 Phases of PRIMARY INTENTION?
Initial phase, Granulation phase, Maturation phase and scare contraction
What are the 3 intentions of Wound Healing: Repair?
Primary, Secondary, Tertiary INTENTION
What wound healing intention is this?
- Lasts 3 to 5 days
- Edges of incision are aligned.
- Blood fills the incision area, which forms matrix for WBC migration.
- Acute inflammatory reaction occurs.
Primary Phase: Iniital Phase
What wound healing intention is this?
- Fibroblasts migrate to site and secrete collagen.
- Wound is pink and vascular.
- Surface epithelium begins to regenerate.
Primary Phase: Granulation Phase
What wound healing intention is this?
- Begins 7 days after injury and continues for several months/years
- Fibroblasts disappear as wound becomes stronger.
- Mature scar forms.
Primary Phase: Maturation phase and scar contraction
