TOPIC 4 Flashcards
pressure ulcers
a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction.
what are some other names for a pressure ulcer?
Pressure sore, decubitus ulcer, or bed sore
what are the three major elements that cause a pressure ulcer?
pressure intensity (tissue ischemia & blanching)
pressure duration
tissue tolerance
tissue ischemia
If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time
blanching
Blanching occurs when the normal red tones of skin are absent.
pressure duration
Pressure duration assesses low and extended pressures. Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death.
tissue tolerance
The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures.
what assessment is included for a pressure ulcer?
-wound location
-depth of tissue involvement (staging)
-type and approximate percentage of tissue in wound bed
-wound dimensions (if present include sinus tracts and tunneling)
-exudate description (if present odor)
-condition of surrounding skin.
what are the risk factors for a pressure ulcer
-Impaired sensory perception
-Impaired mobility
-Alteration in LOC
-Shear
-Friction
-Moisture
stage I
o Intact skin with nonblanchable redness of a localized area usually over a bony prominence
-Discoloration of the skin, warmth, edema, hardness, or pain may also be present.
stage II
o Partial-thickness skin loss involving epidermis, dermis, or both
-Presenting as a shallow open ulcer with a red pink wound bed, without slough.
-May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister.
-Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates deep tissue injury.
stage III
o Full-thickness tissue loss with visible fat but bone, tendon, or muscle are not exposed.
stage IV
o Full-thickness tissue loss with exposed bone, muscle, or tendon
partial thickness wound
Involves the epidermis and the dermis but does not extend through the dermis to the subcutaneous layer
full thickness wound
the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved
Primary intention wound healing
intentional wounds with minimal tissue loss and well approximated edges. low risk for infection (ex: surgical incision)
secondary intention wound healing
a wound involving loss of tissue, is allowed to remain open and heal by granulation, epithelialization, and contraction - used for dirty wounds, o/w abscess can form, greater risk for infection
Tertiary intention wound healing
o Wound that is left open for several days, then wound edges are approximated
granulation tissue
The tissue that normally forms during the healing of a wound
slough
stringy substance attached to wound bed
eschar
black or brown necrotic tissue
exudate
fluid, such as pus, that leaks out of an infected wound
black wound
o black or brown necrotic tissue is eschar, which also needs to be removed before healing can proceed.
yellow wound
soft yellow or white tissue is characteristic of slough (stringy substance attached to the wound bed), and it must be removed by a skilled clinician before the wound is able to heal