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pt management 2 > wounds > Flashcards

wounds Flashcards

1
Q

partial thicknes

A

epidermis and none of the dermis

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2
Q

full thickness

A

epidermis and the entire dermis

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3
Q

what is a skin tear

A

old person bump on the bed post and the skin tears

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4
Q

what are the type of nectrotic tissue

A

slough

eschar

gangrene

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5
Q

transudate

A

water and clear

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6
Q

exudate

A

thicker can be yellow

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7
Q

fistula

A

sinus tract connecting to organ

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8
Q

signs of an acute occlusion

A

pain, pallor, lose of pulse, parathesia, and paralysis

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9
Q

what should ABI be

A

1

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10
Q

arterial wound - pain

A

serve at times

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11
Q

arterial wound - location

A

dorsum of the foot or toes

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12
Q

arterial wound - presentation

A

punched out

pale grannulation tissue

black eschar - gangrene

minimal drainage

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13
Q

arterial wound - periwound

A

thin, shiny skin

loss of hair

pale dusky, cyanotic

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14
Q

arterial wound - pulses

A

decreased or absent

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15
Q

what is the peri wound

A

the tissue surronding the wound

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16
Q

what is venous insuffciency

A

calf pump failure

vein dysfunction

you are not having blood pumped up

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17
Q

what is the most common type of leg ulcer

A

venous insufficency

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18
Q

venous wounds - pain

A

mild to moderate

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19
Q

venous wounds - position

A

medial mall

medial lower leg

areas of trauma

20
Q

venous wounds - presentation

A

irregular

red wound bed

yellow or glossy coating

increased drainage

21
Q

venous wounds - periwound

A

edema

cellulitis

hemsideric

22
Q

venous wounds - pulses

A

normal or decrease

23
Q

risk for venous ulcer

A

DM

trauma

claf pump failure

vien dys

previous ulcer

old

24
Q

how often do you need to turn

A

every 2 hours - before tissue destruction

25
Q

pressure ulcer - pain

A

can be painful

26
Q

pressure ulcer - presentation

A

tri - shear forces
circular - perpendicular forces
abrasions - friction

27
Q

pressure ulcer - position

A

areas of pressure which have sustained contact with seating or lying surface

28
Q

pressure ulcer - periwound

A

non blanchale eythrema

ring of inflammation around nectrosis

29
Q

pressure ulcer - pulse

A

normal - unless concurrent with arterial issue

30
Q

stage 1 - pressure

A

non blanchable erythema

intact skin

pain and or itchiness of the skin

reactive hyperemia

heals in day to weeks

31
Q

stage 2 - ulcer

A

partial thickness - edermis and dermis

abrasion, serum filled blister, shallow crater with a pink bed

heals within days to weeks

32
Q

stage 3 - ulcer

A

full thickness - dermis and epi and subcanteous tissue

may extend to underlying fascia

deep crater with not undermining or tunneling

heal in weeks to months

33
Q

stage 4 - ulcer

A

full thickness - damage to underlying tendon, JC, muscle bone

slough or eschar

undermining often found

heals within weeks to months

34
Q

suspected deeep tissue injury

A

purple or maroon localized discoloration

or

blood filled blister underlying soft tissue damage

35
Q

unstageable

A

depth and therfore stage of a wound cannot be determined unless through eschar or slough

36
Q

should stable/ dry eschar be removed

A

no - natural biological cover

37
Q

risk factor for neuropathic ulcers

A

abnormal foot function

inadequate prof care

length of time with DM

vascular disease

38
Q

neuropathic wounds - pain

A

not painful

39
Q

neuropathic wounds - presentation

A

typically round

40
Q

neuropathic wounds - postition

A

plantar surface of the foot

toes

41
Q

neuropathic wounds - peri wound

A

callused edges, dry edges, thick toe nails

42
Q

neuropathic wounds - pulse

A

normal

43
Q

sanguinous

A

bloody exudate

44
Q

puralent

A

thick, yellow, green, brown,

ordor and infection

45
Q

macerated

A

wet, whitish in apperence

pt management 2 (4 decks)

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