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35 Cards in this Set
- Front
- Back
Pressure ulcers may be described as having _______ or _______ thickness skin loss.
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partial or full thickness skin loss
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removal of infected and necrotic tissue
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debridement
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the use of scalpel, scissors, or other sharp instrument to remove devitalized tissue
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sharp debridement
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the use of wet-to-dry dressing, hydrotherapy, or wound irrigation to remove devitalized tissue
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mechanical debridement
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the application of topical debriding enzymes to devitalized tissue on a wound surface
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enzymatic debridement
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debridement using dressings that are applied to the wound to allow necrotic tissue to self-digest by the action of enzymes present in wound fluids; contraindicated in infected wounds
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autolytic debridement
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Prolonged excessive moisture can result in what?
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maceration
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How does moisture contribute to pressure ulcers?
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causes maceration
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How does heat/fever contribute to pressure ulcers?
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increases metabolic needs; decreases nutrition to ulcer
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How does edema contribute to pressure ulcers?
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tissue fluid increases pressure on blood vessels
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How does obesity contribute to pressure ulcers?
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fatty tissue has decreased blood supply
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How does malnutrition contribute to pressure ulcers?
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causes dry scaly peeling skin; increases the risk for skin breakdown
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Which Stage of a pressure ulcer?:
Erythema that does not go away and does not blanch |
Stage I
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Which Stage of a pressure ulcer?:
Partial thickness skin loss involving epidermis, dermis, or both |
Stage II
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Which Stage of a pressure ulcer?:
Partial thickness skin loss involving epidermis, dermis, or both |
Stage 4
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What is the purpose of monitoring serum albumin?
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indicator of nutritional status
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removal of necrotic tissue so that healthy tissue can regenerate
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debridement
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What is the largest advantage of surgical/sharp debridement?
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it is the most rapid form of debridement
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Mechanical debridement may be done using what (3) methods?
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1. wet-to-dry dressings
2. hydrotherapy (ex. whirlpool) 3. wound therapy (ex. irrigation) |
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Describe the syringe that should be used for mechanical debridement.
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35 mL syringe with a 19 gauge needle/catheter designed to deliver 8 psi
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What is the largest advantage of hydrotherapy and irrigation methods used in mechanical debridement?
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can be used to cleanse granulating wounds and soften eschar
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What is the largest disadvantage of wet-to-dry dressings a method of mechanical debridement?
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they are non-selective removing both nonviable and viable tissue
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the application of topical debriding enzymes to the devitalized tissue on the wound surface
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enzymatic debridement
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method of debridement where dressings are applied to the wound to allow necrotic tissue to self-digest by the action of enzymes present in wound fluids
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autolytic debridement
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formation of new, highly vascular tissue in a healing wound
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granulation
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What is the treatment method for eschar, aka "black" tissue?
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debridement
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PRESSURE ULCER
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localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction
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SUSPECTED DEEP TISSUE INJURY
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purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear Tissue may be painful, firm, mushy, boggy, warmer, or cooler than adjacent tissue may be difficult to detect in dark skin tones
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STAGE I PRESSURE ULCER
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intact skin non-blanchable redness usually over bony prominence may be painful, firm, soft, warmer, or cooler than adjacent tissue may be difficult to detect in dark skin tones
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STAGE II PRESSURE ULCER
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partial thickness loss of dermis shallow open ulcer or intact or open/ruptured serum-filled blister red pink wound bed without slough presents as shiny dry shallow ulcer without slough or bruising this stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation
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STAGE III PRESSURE ULCER
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full thickness tissue loss subcutaneous fat may be visible slough may be present but does not obscure depth of tissue loss may include undermining and tunneling bone/tendon is not visible or directly palpable bridge of nose, occiput and malleolus may develop very shallow stage iii pressure ulcers
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STAGE IV PRESSURE ULCERS
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full thickness tissue loss exposed bone, tendon, or muscle slough or eschar may be present on some parts of wound bed often include underminng and tunneling can extend into muscle and supporting structures (ie. fascia, tendon, joint capsule) making osteomyelitis possible exposed bone/tendon visible and directly palpable
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UNSTAGEABLE PRESSURE ULCER
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full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed stage cannot be determined until enough slough and/or eschar is removed to expose the base of the wound, the true depth
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TRUE OR FALSE: THE STABLE ESCHAR ON THE HEEL SHOULD BE REMOVED
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false. it serves as "the body's natural (biological) cover and should not be removed
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BY WHOM WAS THE PRESSURE ULCER STAGING SYSTEM DEFINED IN 1975? WHAT ORGANIZATION REFINED THE DEFINITIONS, WHICH WERE MADE AVAILABLE IN 2007?
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shea
NPUAP - National Pressure Ulcer Advisory Panel |