Wound/Ostomy Part 2 Flashcards
When would a insurance company pay a hospital for a pressure injury?
When the lesion is stage 3/4 and present on admission. Must be charted within 24 hours of admission.
Describe the epidermis.
5 layers of stratified epithelium. Basal cell layer migrates upward and eventually sloughs off of upper layer (stratum corneum/horny layer). Process takes 30 days. About 45 days for older adults.
How thick is the epidermis?
Approx 20 cells thick
Describe the dermis
Made up of collagen and elastin fibers. Strength, bulk, support, and elasticity. Sensory/motor nerves. Also contains sebaceous glands, sweat glands, hair follicles, capillaries, and lymphatics
Describe subcutaneous tissue
Everything below the dermis. A receptacle for the storage of fat (nutritional storage). Cushion, insulates, and supports other tissues. Vascular supply is between the dermis and subcutaneous tissue.
Describe subcutaneous tissue
Everything below the dermis. A receptacle for the storage of fat (nutritional storage). Cushion, insulates, and supports other tissues. Vascular supply is between the dermis and subcutaneous tissue.
What layer of the skin do stage 1 pressure injuries affect?
Full thickness. All pressure injuries are full thickness injury. DEPTH DOES NOT DETERMINE THE STAGE, BUT RATHER THE STRUCTURES INVOLVED IN THE WOUND BED.
hOW MANY STAGES OF PRESSURE INJIRIES ARE THERE?
4
What is an unstageable pressure injury?
Full thickness tissue loss with slough/eschar
What is a deep tissue injury
Purple skin sometimes filled with blood mushy boggy tissue. Epidermis is still intact.
What pressure injury is after stage 4?
Unstageable (US), and deep tissue injury (DTI)
What are the healing stages?
stage 2, 3, and 4
What is the Braden scale?
scale is 6-23. 6 is highest risk 23 is lowest risk. Test sensory impairment, moisture, mobility, activity, nutrition, friction. Individual sub-scores re more important than overall pressure injury risk.
What is an IAD?
Incontinence associated dermatitis
What should you say when documenting patient turns themselves?
Instead of “self turn” document R, L, B
When do you use the hemodynamic instability guideline?
When you need to run/reposition a patient but they are “too unstabe”