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Adult Health > Chapter 12 exam 1 (b) > Flashcards

Chapter 12 exam 1 (b) Flashcards

1
Q

How many STAGES are there in PRESSURE ULCERS?

A

(4) Stage 1, 2, 3, 4
-Stage I (minor) to stage IV (severe)

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2
Q

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

A

Stage 1

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3
Q

Describe a Stage 1 Pressure Ulcer?

A

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

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4
Q

Describe a Stage 2 Pressure Ulcer?

A
  • Partial-thickness loss of dermis
  • Shallow open ulcer with red pink wound bed
  • Presents as an intact or ruptured serum-filled blister
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5
Q

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

A

Stage 2

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6
Q

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.

A

Stage 3

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7
Q

Describe Stage Pressure 3 Ulcer?

A
  • 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.
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8
Q

Describe Stage IV Pressure Ulcer?

A
  • 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.
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9
Q

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.
A

Stage 4

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10
Q

Identify risk factors and implement prevention strategies. (3)

A
  • Mobilization
  • Frequent repositioning
  • Devices
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11
Q

What examples of Prevention (Devices)?

A
  • 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
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12
Q

What are Skin Care Prevention?

A
  • 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.
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13
Q

In PREVENTION what is the CALORIC INTAKE ELEVATED to?

A

30 to 35 cal/kg/day or 1.25 to 1.50 g protein/kg/day

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14
Q

In PREVENTION what is the CALORIC INTAKE ELEVATED to regarding CAL/KG/DAY? What is the Number?

A

30 to 35

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15
Q

In PREVENTION what is the CALORIC INTAKE ELEVATED to regarding PROTEIN/KG/DAY? What is the Number?

A

1.25 - 1.50

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16
Q

Treatment what is COCA?

A

Document and describe size, stage, location, exudate, infection, pain, and tissue appearance.

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17
Q

What are some Ulcer Care Treatments?

A
  • 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.
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18
Q

What are some examples of SURGICAL REPAIR in pressure ulcer treatments?

A
  • Skin grafts
  • Skin flaps
  • Musculocutaneous flaps
  • Free flaps
19
Q

In providing Ambulatory and Home Care, What do you do for the Patient?

A

Education of both the patient and the caregiver in prevention techniques is extremely important.

20
Q

What are the 3 Phases of PRIMARY INTENTION?

A

Initial phase, Granulation phase, Maturation phase and scare contraction

21
Q

What are the 3 intentions of Wound Healing: Repair?

A

Primary, Secondary, Tertiary INTENTION

22
Q

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.
A

Primary Phase: Iniital Phase

23
Q

What wound healing intention is this?

  • Fibroblasts migrate to site and secrete collagen.
  • Wound is pink and vascular.
  • Surface epithelium begins to regenerate.
A

Primary Phase: Granulation Phase

24
Q

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.
A

Primary Phase: Maturation phase and scar contraction

25
Q

Describe Secondary Intention

A
  • Wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss.
  • Edges cannot be approximated.
  • Results in more debris, cells, and exudate
26
Q

Describe Tertiary Intention

A
  • Delayed primary intention due to delayed suturing of the wound
  • Occurs when a contaminated wound is left open and sutured closed after the infection is controlled
27
Q

What do you do in providing an ASSESSMENT on wound and the healing process?

A

-Assess on admission and on a regular basis.
-Record the COCA and report if abnormal for the situation.
-Staphy and Psudomonas cause purulent drainage
-If wound fails to heal ASSESS for what may delay healing

28
Q

In NURSING IMPLEMENTATION the Purposes of wound management are? (3)

A
  • Cleaning a wound
  • Treating infection
  • Protecting clean wound from trauma
29
Q

What are?

  • may only need cleansing.
  • Adhesive strips or tissue adhesives may be used instead of sutures.
  • Treatment plan can include covering these wounds with a film dressing to provide a moist healing environment and wound protection from trauma.
A

Superficial skin injuries

30
Q

What are?

  • closed by suturing the edges together
  • If wound is contaminated, it must be converted into a clean wound before healing can occur normally.
  • Debridement of a wound that has multiple fragments or devitalized tissue may be necessary.
A

Deeper skin wounds

31
Q

What intention is this?

  • wounds may be covered with dry dressing.
  • Drains may be inserted.
  • Topical antimicrobials/ antibacterials should be used with caution.
A

Primary Intention

32
Q

What intention is this?

-wound care depends on etiology and type of tissue in the wound.

A

Secondary Intention

33
Q

How do you take care of RED WOUNDS?

A
  • Protect the wound

- Gentle cleaning, if needed

34
Q

How do you take care of YELLOW WOUNDS?

A
  • Dressing that absorbs exudate and cleanses the wound surface
  • Hydrocolloid dressings
35
Q

How do you take care of BLACK WOUNDS

A

Debridement of nonviable, eschar tissue

36
Q

What is important about Negative-pressure wound therapy (vacuum-assisted wound closure)?

A
  • Suction removes drainage and speeds healing.

- Monitor serum protein levels, F&E balance, and coagulation studies.

37
Q

What consists of Nutritional Therapy for Pressure Ulcer patients?

A

Diet high in protein, carbohydrates, and vitamins with moderate fat

38
Q

What consists of Drug Therapy for Pressure Ulcer patients?

A

Becaplermin (Regranex)

39
Q

What is Hyperbaric 02 Therapy (HBOT)?

A
  • Delivery of O2 at increased atmospheric pressure
  • Allows O2 to diffuse into serum
  • Last 90 to 120 minutes, with 10 to 60 treatments
40
Q

Infection prevention consists of what (3) important things?

A
  • Do not touch recently injured area.
  • Keep environment free from possibly contaminated items.
  • Antibiotics may be given prophylactically.
41
Q

What is important in infection control that a Nurse must IMPLEMENT?

A
  • Culture should be done.
  • Concurrent swab specimens obtained from
  • Wound exudate
  • Z-technique
  • Levine’s technique
42
Q

What are Psychologic implications to consider with a Pt who has Pressure Ulcers?

A
  • Fear of scar or disfigurement
  • Drainage or odor concerns
  • Be aware of your facial expressions while changing dressing.
43
Q

What teaching must the Nurse provide for a Patient with Pressure Ulcers?

A
  • Teach signs and symptoms of infection.
  • Note changes in wound color or amount of drainage.
  • Provide medication teaching.

Adult Health (9 decks)

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