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27 Cards in this Set
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- Back
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pressure
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the force that is applied vertically or perpendicular to the surface of the skin. Pressure compresses underlying tissue and small blood vessels hindering blood flow and nutrient supply. Tissues become ischemic and are damaged or die.
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shear
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when one layer of tissue slides horizontally over another, deforming adipose and muscle tissue, and disrupting blood flow
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sites at risk for pressure ulcers
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bony prominences
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how to stage decubiti
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The pressure ulcer should be staged according to the maximum anatomic depth of tissue damage
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Stage I
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The pressure ulcer should be staged according to the maximum anatomic depth of tissue damage
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Stage II
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Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage II pressure ulcers may also present as an intact or open/ruptured serum-filled or serosangineous-filled blister.
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Stage III
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Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. Stage III pressure ulcers may include undermining and tunneling.
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Stage IV
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Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. These ulcers often include undermining and tunneling.
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friction
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rubbing of skin against rough surface
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What are sources of moisture that can impact skin integrity?
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Incontinence, diaphoresis, wound exudate, spilled water or other fluids
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What are some intrinsic factors in the development of pressure ulcers?
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Immobility, impaired sensation, malnourishment, aging, fever, low blood pressure.
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What are some extrinsic factors in the development of pressure ulcers?
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Friction, shearing, moisture
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primary intention wound healing
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wound is mechanically closed (sutures, staples, or surgical glue
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secondary intention wound healing:
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wound heals from the bottom up through granulation
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intention wound healing
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: the wound begins to heal by secondary intention, and once is partially granulated is then surgically closed with sutures
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evisceration
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evisceration is dehiscence PLUS internal body contents coming out through the dehisced wound and being on the outside of the body.
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Dehiscence
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the opening up of a sutured or stapled wound
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appearance of serous drainage
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Clear
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What causes serous drainage?
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Serum leaking from capillaries of a clean wound
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appearance of sanguineous drainage
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Bloody, red
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cause of sanguineous drainage
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Bleeding, from damage to capillaries; seen in deep wounds or highly vascular tissue
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appearance of serosanguineous drainage
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Bleeding, from damage to capillaries; seen in deep wounds or highly vascular tissue
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cause of serosanguineous drainage
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Bleeding, from damage to capillaries; seen in deep wounds or highly vascular tissue
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appearance of purulent drainage
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Pus-like: yellow, green, brown, or blue
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cause of purulent drainage
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indicates infection
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appearance of purosanguineous drainage
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Blood and pus
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cause of purosanguineous drainage
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Pus in an infected wound that also has ruptured capillaries
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