Week 4 Flashcards
What is the braden scale?
A mobility assessment
What does a higher score on the braden scale mean?
More mobile
What is stage 1 pressure ulcer?
- Non-blanchable (skin does not change color after pressing down, stays red)
- Lowered tissue perfusion
What is stage 2 pressure ulcer?
Partial skin loss
What is stage 3 pressure ulcer?
Full thickness skin loss down to ADIPOSE
What is stage 4 pressure ulcer?
Thickness skin loss exposing MUSCLE AND BONE
What procedure is done to remove eschar?
Debridement
Serous drainage
Clear, watery plasma
Sanguineous
Red, bloody
Serosanguineous
Light red to pink, blood tinged
Purulent drainage? What does it mean?
Yellow, thick with WBCs
- Infection
Purosanguineous
Pus and blood
Primary wound healing
-Wound is approximated/parallel
- Can stitch shut
Secondary Wound healing
- Not approximated
- Wound is left open to heal, we pack it with gauze
Delayed primary closure or tertiary wound healing
-Combination of primary and secondary
-Wound is left open for 5-10 days before it is closed with sutures
Dehiscence wound
Wound splits open
Evisceration wound
Organs protrude out of wound
Steps for enema?
1) Tube goes into rectum
2) Have patient lay in SIM’s position
3) Hang bag on IV pole 12 - 18 inches above rectum
4) They hold for 5 - 10 minutes, then can go to restroom
What is a normal color of a stoma?
Red
What is docusate sodium?
- Stool softeners (for constipation)
Pt. education for docusate sodium?
- Takes 3-5 days to take effect
-Take with glass of water
What is bisacodyl?
- A laxataive
Pt. education for bisacodyl?
- Do not give regularly because body will get used to it
