MSI Flashcards
in order for pressure ulcers to heal ______ _____ must be corrected
Protein deficiency
foods high in protein
tofu, eggs, meat, fish, cheese
anoxia
absence of oxygen
contributing factors to pressure ulcers
immobility prominent boney areas subcutaneous tissues congnition sensory perception nutrition shear mostiure
gerontological considerations
skin thickness elasticity collagen sebaceous sweat glands
pressure ulcer sites
occiput ear scapula elbow sacrum greater trochanter ischial tuberosities medial condyle of tibia fibular head medial malleolus lateral malleolus heel
the lower the braden score…. the higher the ___ is
risk for pressure ulcer
braden score considers what?
sensory perception degree of moisture on skin activity mobility nutrition friction and shear
stage 1 pressure ulcer
erythmea intact skin no blanching colors may differ (possibly purple) painful, soft, hot or cold
stage 2 pressure ulcers
partial thickness
loss of dermis
may be a blood filled blister
may be shiny or dry with out slough or blistering
stage 3 pressure ulcer
full thickness tissue loss
subcutaneous layer may be visible but tendon bone or muscle is not exposed
stage 4 pressure ulcer
full thickness
can see tendons or bone
slough and eschar
may include tunneling
what is possible with a stage 4 pressure ulcer
osteomyletsis
unstageable pressure ulcers
base of the would cannot be seen
eschar that should not be removed
if it is stable, it is the bodies natural covering and healing
treatment of stage I pressure ulcers
improve risk factors relieve pressure improve nutrition fluid and electrolyte balance moisture friction and shear
treatment of stage II pressure ulcers
(include all things of stage I pressure ulcer treatment)
cleanse gently
avoidance
dressing changes
treatment of stage III and V pressure ulcers
mechanical flushing topical enzyme debriedment surgical debridement skin grafts physical therapy diet
assessments when assessing pressure ulcer dressings
drainage
constriction
sensation
irritation from the tape
complete fracture
involves a break that is across a cross section
incomplete fracture
involves a break through part of the cross section of the bone
pathological fracture
a fracture due to a diseased bone
comminuted fracture
produces several bone fragments
closed fracture
does not cause a break in the skin
open fracture
skin or mucus membrane wound extends to the fractured bone
intrarticular fracture
cartilaginous
stage 1 fractures
less that 1 cm
stage 2 fractures
larger wound with out extensive tissue damage
stage 3 fracture
highly contaminated with large amounts of tissues damage, may be accompanied by traumatic amputation
signs of a fracture
acute pain loss of function deformity shortening of the extremity crepitus localized edema and ecchymosis
emergency management of fractures
immobilize fracture at the joints proximal and distal to the fracture
adequate splinting
assess neurovascular status and pulses proximal and distal to fracture
fracture reduction
restoration of the fracture fragments to anatomical alignment and positioning
closed reduction
bringing the fragments together with manual traction (cast splint and other devices)
fiberglass cast
comprised of polyurethane has more versitility than plaster
lighter
stronger
more water resistant
reaches full rigidity within 30 minutes of application
plaster cast
made of plaster less costly achieves a better mold than fiber glass heavy not water resistant
traction
application of pulling force to realign a joint
decreases muscle spasms and pain
realignment of bones and corrections orprevention of deformities
straight or running traction
applies the pulling force straight in line with the body in bed
buck extension traction
skin traction to the lower leg
skin traction
applied to skin
skeletal traction
applied directly to the bony skeleton
intracapsular fracture
fractures of the neck of the femur
extracapsular fracture
fractures of the trochanter region and between the base of neck and the lesser trochanter of the subtrochanteric area
gerentological considerations
less bone density
stress and immobility
confusion muscle weakness
