Chapter 34 Flashcards
Avoidable pressure ulcer
A pressure ulcer that develops from the improper use of the nursing process
Bedfast
Confined to a bed
bony prominence
An area where the bone sticks out or projects from the flat surface of the body
Chairfast
Confined to a chair
Colonized
The presence of bacteria on the would surface or in the wound tissue; the person does not have signs or symptoms of an infection
Epidermal stripping
Removing the epidermis as tape is removed from the skin
Eschar
Thick, leathery dead tissue that may be loose or adhered to the skin; it is often black or brown
Friction
The rubbing of one surface against another
Pressure ulcer
A localized injury to the skin and or underlying tissue usually over a bony prominence resulting from pressure in combination with a sear or friction
Shear
When the layers of the skin rub against each other; when the skin remains in place and underlying tissue move and stretch and tear underlying capillaries and blood vessels cause tissue damage
Slough
Dead tissue that is shed from the skin; it is usually light colored, soft, moist; may be stringy at times
Unavoidable pressure ulcer
A pressure ulcer that occurs despite efforts to prevent one through proper use of the nursing practice
Pressure ulcer stage 1
color doesn’t return when relieved of pressure. may be red, blue or purple
Pressure ulcer stage 2
partial skin loss, looks like a blister, skin may or may not be intact
Pressure ulcer stage 3
full thickness, subcutaneous fat may be exposed, dead tissue or slough
