Inflammation
Pressure Injury Risk/Prevention
Pressure Injury Staging
Pressure Injury Assessments Complications/Treatments
100
Fever, tachycardia, malaise, fatigue, nausea, anorexia, elevated WBCs with a shift to the left.
What are the systemic clinical manifestations of an infection?
100
A nursing intervention for a bedridden patient
Turn and reposition every 2 hours
100
Full thickness loss of skin where adipose tissue is visible in the injured area.
What are clinical manifestations of a stage III pressure injury?
100
This treatment draws the wound edges together by negative pressure
A vacuum-assisted closure device (wound vac)
200
A laceration with edges that do not approximate an granulation tissue fills the wound.
What is a a wound that heals by second (secondary) intention?
200
Dietary measures to promote wound healing include...
A diet high in protein, carbohydrates, and vitamins
200
A type of pressure injury
Medical device pressure injury
200
A nursing action when a wound dehisces.
Cover the wound with a sterile saline dressing.
300
Systemic and local reactions.
What is the normal response to inflammation?
300
Three risk factors for pressure injuries include...
Anemia, diabetes, advanced age, incontinence, poor perfusion, immobility
300
A type of pressure injury
Deep tissue injury
300
Priority nursing actions for yellow-purulent drainage on a post-op wound
Obtain a wound culture
400
High wbc count with immature forms of neutrophils is called...
A "shift to the left"
400
Infection prevention and control includes...
Handwashing, reducing contamination of the wound, astute assessments, obtaining wound cultures, patient/caregiver education
400
A type of pressure injury requires debridement prior to being staged?
Unstageable pressure injury
400
Name 5 complications of wound healing
Adhesions, excessive contraction, dehiscence, evisceration, excessive granulation, fistula formation, infection, hemorrhage, hypertrophic scars, keloid formation.