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Flashcards in would care II Deck (48)
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1

What phase: red, swollen, firm, warm

inflammatory

2

Evidence of epitheliazation

pale pink cells

3

Mature characteristics

flat, white, pale, soft

4

immature characteristics

raised, red, rigid

5

3 depths of a wound

superficial
partial thickness
full thickness

6

wound extends into epidermis, dermis or both but not subcutaneous

partial thickness

7

epidermis, dermis, subcutaneous

full thickness

8

What are the six stages of pressure injuries

Stage 1-4
unstageable
deep tissue pressure

9

intact skin with non-blanchable erythema

Stage I Non blanchable erythema of intact skin

10

partial thickness skin loss with exposed dermis, viable, pink or red, moist and may present intact or ruptured blister

Stage II Partial thickness skin loss with exposed dermis

11

full thickness loss of skin, fat is visible and ulcer and granulation tissue and epibole (round edges) are often present
-undermining and tunneling may occur
-slough and eschar

stage III Full thickness skin loss

12

full thickness skin and tissue loss with exposed palpable fascia, muscle, tendon ligament or cartilage in the ulcer
-rolled edges, tunneling, undermining often

Stage IIII Full thickness skin and tissue lost

13

when full thickness skin and tissue loss to the extent of tissue damage cannot be determined due to slough or eschar

unstageable pressure injury

14

non blanch able deep red, maroon, or purple revealing dark wound blood or blood filled blister

Deep Tissue Pressure Injury

15

if slough or eschar obscures the extent of the tissue loss this is considered what type of pressure injury?

unstageable

16

Characteristics of Venous Ulcer

-proximal to med. malleolus
-irregular shape
-excessive exudation
-pinkish-red base
-brown purple discoloration

17

Five interventions for venous ulcers

1. pliable non stretchable dressing
2. fitted socks
3. gentle rinsing basin
4. intermittent compression (jobst pump)
5. mild weight bearing exercise

18

superior to lateral malleolus, feet, and toes
irregular shape
pale base with poor granulation
severe pain
gangrene

Ischemic or arterial ulcers

19

Should you elevate arterial ulcers?

NO

20

What are three types of burns

thermal
chemical electrical

21

When are scalds most prevalent?

Children 1-5 years

22

Who is at most risk for for flammable liquid burns?

men 17-30 years

23

Three zones of tissue damage from burns?

Hyperemia
coagulation
stasis

24

irreversible damage in a burn

coagulation zone

25

injured, dies without intervention in burn

stasis

26

minimal cell damage, recovers in burn

hyperemia zone

27

Describe five depths of a burn injury?

Superficial ( epidermis only, sunburn, no blisters)
Superficial Partial Thickness (upper layers of dermis, intact blisters)
Deep partial Thickness ( destruction of epidermis, dermis)
Full Thickness ( ruined epidermis and dermis, no pain. may reach fat)
Subdermal ( can reach bone and muscle)

28

what depth of a burn is it if destructs the epidermis and severe damage to dermis. Mixed red and white color, nerve endings can be damaged, along with hair and sweat glands

Deep Partial Thickness

29

Complete destruction of epidermis and dermis, no pain, subcutaneous fat may have damage is what depth of burn

Full thickness burn

30

Complete destruction of all tissue from epidermis to subcutaneous tissue including muscle and bone

Subdermal burn