Chapter 48 Flashcards
Distinguish between the epidermis, dermis, and dermal layers of the skin.
- epidermis: top layer of skin
-
dermis: inner layer of skin
- contains collagen
- dermal: epidermal junction; separates dermis and epidermis
What is a pressure injury? Why does it occur? How can you determine a pressure injury?
– localized damage to the skin and underlying soft tissue taht results from unrelieved, prolonged pressure
– occurs because blood flow is limited to that area due to pressure
– appears red and non-blanchable
What are the 6 risk factors for pressure injuries?
- impaired sensory perception
- impaired mobility
- alteration in LOC (levels of consciousness)
- shear
- friction
- moisture
What is ischemia?
decreased blood supply to an area
What is hyperemia (erythema)?
redness
Define blanchable.
color lightens when pressure is applied
Define non-blanchable.
stays red (hyperemia/erythema) despite pressure application
What is shear force? When does it occur?
– shear force: sliding movement of the skin and subq tissue while underlying muscle/bone are stationary
– occurs when HOB is raised or during pt transfers
What is friction?
effects of rubbing or resistance that a moving body meets from the surface where it moves
Distinguish the 4 stages of pressure ulcer classifications.
- stage 1: non-blanchable erythema of intact skin
- stage 2: partial-thickness skin loss with exposed dermis
- stage 3: full-thickness skin loss, exposed adipose tissue, rolled wound edges
- stage 4: pressure injury = full-thickness skin and tissue loss, exposed muscle/ligament/cartlidge/bone/tendon, may have granulated tissue loss
What is a deep tissue injury?
non-blanchable, dark discoloration of skin (either intact or not)
called this because it is not possible to determine how deep the injury goes
Distinguish between granulation tissue, slough, eschar, and exudate.
- granulation tissue: new, healthy tissue; pink/red; indicates wound is healing
- slough: dead tissue; creamy/yellow color
- eschar: dry, black, hard, necrotic tissue
- exudate: drainage
What is the difference between partial-thickness wounds and full-thickness wounds?
- patial-thickness wounds: epidermis (superficial layers) are affected
- full-thickness wounds: epidermis and dermis layers are affected
What is the difference between primary intention and secondary intention? What do they indicate about a wound?
-
primary intention: clean, approximated (closed) edges
- low risk of infection
-
secondary intention: edges not approximated
- likely due to tissue loss or contamination
– these terms describe what wound edges look like
Concerning exudate (drainage), define serous, purulent, sanguinous, and serosanguinous.
- serous: clear, thin, watery drainage; normal in wound-healing process
- purulent: opaque, viscous, yellow/green colored drainage; indicates infection
- sanguinous: bloody drainage
- serosanguinous: mix of serous and sanguinous drainage; pink color
What is hemorrhage?
bleeding
What does infection look like in wound healing? (5)
- purulent drainage that may change color
- odored
- redness (hyperemia/erythema)
- fever
- pain
What is dehiscence?
opening/separation of wound layers; loss of approximation
What is evisceration?
wound opens and something comes out of it
this is an emergency situation
Where do pressure injuries mainly occur? What is the best way to prevent them?
– occurs mostly on bony prominences
– best prevention is to reposition pts q2h and inspect pt skin daily
What is the difference of hot and cold therapies/what purposes do they serve?
– hot:
- vasodilation – improves blood flow
– cold:
- vasoconstriction – decreases inflammation and swelling
- decreases pain
- useful for soft tissue injuries
When is moisture therapy useful? (3)
- improves muscle and ligament flexibility
- relaxation
- decreases pain/stiffness
