Shared Flashcard Set

Details

wounds (pressure ulcers)
n/a
10
Nursing
Not Applicable
10/11/2010

Additional Nursing Flashcards

 


 

Cards

Term
pathophysiology of pressure ulcers
Definition
vascular compromise, tissue anoxia, and cell death
Term
(new) pressure ulcer stages
Definition

(Suspected) Deep Tissue Injury,

Stage I, II, III, IV and

     U (unstageable)

Term
stage 1 pressure ulcer
Definition

Intact skin with non-blanchable redness of a localized area usually over a bony prominence

usually cooler, or warmer to touch

Term
stage 2 pressure ulcer
Definition

Partial thickness loss of dermis presenting as a shiny, dry, shallow open ulcer with a red pink wound bed, without slough

Term
stage 3 pressure ulcer
Definition

Full-thickness tissue loss.  Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present,May include undermining and tunneling

Term
stage 4 pressure ulcer
Definition

Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. 

Term
unstageable pressure ulcer
Definition

Full thickness 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. 
dont know the depth, severity or stage until the eschar is removed.

Term
suspected deep tissue injury
Definition

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 that is painful, firm, mushy, boggy, warmer or cooler 

Term
pressure ulcer treatment
Definition

#1 relieve the pressure

#2 Turn, turn, turn

#3 specialty beds

#4 topical wound care

Term
prevent pressure ulcers
Definition

-Topical skin care:

skin, dry and clean

use moisture barrier creams

absorbent chux

-Positioning

hob at least 30degrees

reposition pt every 2 hours

use postioning devices

limit sitting in chairs to 2 hours

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