Chapter 48 Flashcards
Tough fibrous protein
Collagen
Is localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination of shear and or friction.
Pressure ulcer
Does not blanch
Dark pigmented skin
Inner layer of the skin that provides tensile strength and mechanical support
Dermis
Normal red tones of light skin patients are absent
Blanching
Top layer of the skin
Epidermis
Identify the 3 factors that contribute to pressure ulcer development?
> pressure intensity
pressure duration
pressure tolerance
What are hue he risk factors for pressure ulcer development?
- Impaired sensory perception
- Alterations of levels of consciousness
- Impaired mobility
- Shear
- Friction
- Moisture
Red moist tissue composed of new blood vessels which indicates wound healing
Granulation tissue
Stringy substance attached to wound bed that is soft, yellow, or white tissue
Slough
Black or brown necrotic tissue
Eschar
Describes the amount, color, consistency, and odor of wound drainage
Exudates
Wound that is closed closed by epitheliazation with minimal scar formation
Primary intention
Wound that is left open until it becomes filled by scar tissue, chance of infection is greater
Secondary infection
Pressure applied exceed s the normal capillary pressure and the vessel is occluded for a longed period of time.
Tissue ischemia
If the pressure is relieved and the blood flow returns the skin turns ____.
Red
The effect of this redness is vasodilation ( blood vessel expansion) it is called ______.
Hyperemia
Evaluate an area of hypermedia by pressing a finger over affected area. If it blanches ( turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, is called ______.
Blanching hyperemia
If the erythematosus does not blanch (non blanching erythema) when you apply pressure, ________ tissue damage is probable
Deep
Occurs when the normal red tones of the light skinned patient are absent
Blanching
Extended pressure occludes blood flow and nutrients and contributes to cell death
Pressure duration
The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures.
Tissue tolerance
Is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary.
Shear
> when shear is present, the skin and subcutaneous layers adhere to the surface of the bed! and the layers of muscle and bone slide in hue he direction of body movement.
The force of two surfaces moving across one another such as mechanical force exerted when skin is dragged across a coarse surface as bed lines is called______.
Friction