ch. 48 Skin health and wound healing Flashcards
(18 cards)
pathogenesis of pressure ulcers
- pressure intensity
- pressure duration
- tissue tolerance
Hyperamia
if pressure is relieved and blood flow returns, the skin turns red .. no blanching?? tissue damage is possible.
risk factors for pressure ulcer dev.
- impaired sensory perception
- impaired mobility
- alteration in LOC
- shear & friction
stage 1 ulcer
redness and skin is still intact
stage 2 ulcer
partial thickness skin loss involving epidermis, dermis, or both
stage 3 ulcer
full thickness tissue loss with visible fat
stage 4 ulcer
full thickness tissue loss with exposed bone, muscle, or tendon
wound def.
granulation tissue
slough
eschar
exudate
clean surgical incision
little tissue loss, heal by primary intention. approximated edges
secondary intention
burn, pressure ulcer, severe laceration-wound..
wound is left open until it becomes filled by scar tissue
partial-thickness wound
shallow wound involving loss of epidermis and possible partial loss of dermis
full thickness wound
extend into dermis.
-healing process involves 3 phases: the inflammatory phase, proliferative phase, and remodling
braden scale
sensory perception, moisture, activity, mobility, nutrition and friction and shear
norton scale
physical and mental condition, activity, mobility, and incontinence
factors influencing pressure ulcer formation and wound healing
- nutrition
- tissue perfusion
- infection
- age
- psycho-social impact of wounds
attitudes
- discipline
- diligence
- creative
assessment
-skin, presence of ulcers, mobility, nutrition and fluids, body fluids, pain, existing wounds, wound drains, wound culture
avoid pressure points
with the 30 degree hip turn on bed with pillow inbetween legs
