Chapter 48 Flashcards
Distinguish between the epidermis, dermis, and dermal layers of the skin.
- epidermis: top layer of skin
-
dermis: inner layer of skin
- contains collagen
- dermal: epidermal junction; separates dermis and epidermis
What is a pressure injury? Why does it occur? How can you determine a pressure injury?
– localized damage to the skin and underlying soft tissue taht results from unrelieved, prolonged pressure
– occurs because blood flow is limited to that area due to pressure
– appears red and non-blanchable
What are the 6 risk factors for pressure injuries?
- impaired sensory perception
- impaired mobility
- alteration in LOC (levels of consciousness)
- shear
- friction
- moisture
What is ischemia?
decreased blood supply to an area
What is hyperemia (erythema)?
redness
Define blanchable.
color lightens when pressure is applied
Define non-blanchable.
stays red (hyperemia/erythema) despite pressure application
What is shear force? When does it occur?
– shear force: sliding movement of the skin and subq tissue while underlying muscle/bone are stationary
– occurs when HOB is raised or during pt transfers
What is friction?
effects of rubbing or resistance that a moving body meets from the surface where it moves
Distinguish the 4 stages of pressure ulcer classifications.
- stage 1: non-blanchable erythema of intact skin
- stage 2: partial-thickness skin loss with exposed dermis
- stage 3: full-thickness skin loss, exposed adipose tissue, rolled wound edges
- stage 4: pressure injury = full-thickness skin and tissue loss, exposed muscle/ligament/cartlidge/bone/tendon, may have granulated tissue loss
What is a deep tissue injury?
non-blanchable, dark discoloration of skin (either intact or not)
called this because it is not possible to determine how deep the injury goes
Distinguish between granulation tissue, slough, eschar, and exudate.
- granulation tissue: new, healthy tissue; pink/red; indicates wound is healing
- slough: dead tissue; creamy/yellow color
- eschar: dry, black, hard, necrotic tissue
- exudate: drainage
What is the difference between partial-thickness wounds and full-thickness wounds?
- patial-thickness wounds: epidermis (superficial layers) are affected
- full-thickness wounds: epidermis and dermis layers are affected
What is the difference between primary intention and secondary intention? What do they indicate about a wound?
-
primary intention: clean, approximated (closed) edges
- low risk of infection
-
secondary intention: edges not approximated
- likely due to tissue loss or contamination
– these terms describe what wound edges look like
Concerning exudate (drainage), define serous, purulent, sanguinous, and serosanguinous.
- serous: clear, thin, watery drainage; normal in wound-healing process
- purulent: opaque, viscous, yellow/green colored drainage; indicates infection
- sanguinous: bloody drainage
- serosanguinous: mix of serous and sanguinous drainage; pink color
