would care II Flashcards
What phase: red, swollen, firm, warm
inflammatory
Evidence of epitheliazation
pale pink cells
Mature characteristics
flat, white, pale, soft
immature characteristics
raised, red, rigid
3 depths of a wound
superficial
partial thickness
full thickness
wound extends into epidermis, dermis or both but not subcutaneous
partial thickness
epidermis, dermis, subcutaneous
full thickness
What are the six stages of pressure injuries
Stage 1-4
unstageable
deep tissue pressure
intact skin with non-blanchable erythema
Stage I Non blanchable erythema of intact skin
partial thickness skin loss with exposed dermis, viable, pink or red, moist and may present intact or ruptured blister
Stage II Partial thickness skin loss with exposed dermis
full thickness loss of skin, fat is visible and ulcer and granulation tissue and epibole (round edges) are often present
- undermining and tunneling may occur
- slough and eschar
stage III Full thickness skin loss
full thickness skin and tissue loss with exposed palpable fascia, muscle, tendon ligament or cartilage in the ulcer
-rolled edges, tunneling, undermining often
Stage IIII Full thickness skin and tissue lost
when full thickness skin and tissue loss to the extent of tissue damage cannot be determined due to slough or eschar
unstageable pressure injury
non blanch able deep red, maroon, or purple revealing dark wound blood or blood filled blister
Deep Tissue Pressure Injury
if slough or eschar obscures the extent of the tissue loss this is considered what type of pressure injury?
unstageable
Characteristics of Venous Ulcer
- proximal to med. malleolus
- irregular shape
- excessive exudation
- pinkish-red base
- brown purple discoloration
Five interventions for venous ulcers
- pliable non stretchable dressing
- fitted socks
- gentle rinsing basin
- intermittent compression (jobst pump)
- mild weight bearing exercise
superior to lateral malleolus, feet, and toes irregular shape pale base with poor granulation severe pain gangrene
Ischemic or arterial ulcers
Should you elevate arterial ulcers?
NO
What are three types of burns
thermal
chemical electrical
When are scalds most prevalent?
Children 1-5 years
Who is at most risk for for flammable liquid burns?
men 17-30 years
Three zones of tissue damage from burns?
Hyperemia
coagulation
stasis
irreversible damage in a burn
coagulation zone
injured, dies without intervention in burn
stasis
minimal cell damage, recovers in burn
hyperemia zone
Describe five depths of a burn injury?
Superficial ( epidermis only, sunburn, no blisters)
Superficial Partial Thickness (upper layers of dermis, intact blisters)
Deep partial Thickness ( destruction of epidermis, dermis)
Full Thickness ( ruined epidermis and dermis, no pain. may reach fat)
Subdermal ( can reach bone and muscle)
what depth of a burn is it if destructs the epidermis and severe damage to dermis. Mixed red and white color, nerve endings can be damaged, along with hair and sweat glands
Deep Partial Thickness
Complete destruction of epidermis and dermis, no pain, subcutaneous fat may have damage is what depth of burn
Full thickness burn
Complete destruction of all tissue from epidermis to subcutaneous tissue including muscle and bone
Subdermal burn
clear drainage
serous
blood tinged drainage(vessel dialation)
serosanguineous
creamy yellowish containing neutrophils, macrophils, RBC and WBC
Exudate
scab
dessication
yellow or yellow whitish, dried exudate
Slough
white colored, healthy tissue,over hydrated
maceration
undermining, crescent shaped wound
undermining
tract/sinus deep wound
tunneling
Describe Ankle Brachial Index
measure brachial (SBP) and ankle SBP in supine and divide ankle/brachial should be about 1.0, if less than .8 arterial insufficiency
What are the ranges for normal, borderline perfusion, severe ischemia, and critical limb ischemia?
NOrmal 1.0-1.3
Severe ischemia
Turbulane sound or wooshing
bruits
Name three arterial vascular tests
- rubor of dependency
- venous filling time
- claudication time
Describe Rubor of Dependency (arterial test)
patient supine
leg elevated 60 degrees for 1 min (normal has no color change, pallor presents if insufficient blood flow)
when leg is placed below heart level, color will change form pink to bright red
What causes an abnormal reading of Rubor of Dependency (arterial)
due to reactive hyperemia or rubor or dependency compensating for tissue hypoxia
(if its a venous problem veins will allow the blood to back and area will change)
Describe Venous Filling Time (arterial test)
- only works in people with competent venous sytems
- patient supine at 60 degrees for 1 min then returned
- record filling time
- if greater than 10-15 = arterial problems
Describe Claudication time (arterial test)
treadmill walk for 1 mile until calf pain
What are three venous tests for vasculature?
- percussion test
- trendelenburg’s Test (should take about 30 seconds if not, incompetent)
- Holms Sign (DVT test)
What should a light touch sensation feel like
10g or 5.07 filament
