terms
risk factors
factors wound healing
healing process
ulcer prevention
100
bed ulcer, decubidus
What is other names for pressure ulcer
100
force exerted against the skin while the skin remains stationary while the bony structures move.
What is shear?
100
immobility
What is creates pressure on bony prominises with small amount of subcutaneous?
100
primary intention
What is approximate, straight edges (well approximated), surgical wound?
100
remember at high risk when doing this adequacy of sensory perception- are they aware as they age? use two point discrimination moisture- continent or incontinent, increase risk for skin breakdown activity- ability to ambulate or turn nutrition- bein positive nitrogen balance smoking will decrease o2 and blood flow to wound friction and shear lifestyle- smoking, alcohol, how many drinks they consume medications- steriod (prenezone), high dose aspirin, chemotherapeutic, antineoplastics developmental- healthy adults heal more quickly
What is assessment?
200
lack of blood flow to particular area and is deprived of oxygen
What is tissue ischemia?
200
friction
What is results from two surfaces rubbing against one another?
200
inadequate nutritio
What is lack of protein leads to weight loss, muscle atrophy, loss of subcutaneous tissue?
200
granulation tissue, edges not well approximated, extensive wound, ex. increased scaring, risk for infection is greater risk of infection
What is secondary intention?
200
skin care and early treatment
What is make sure to have preventive measures in place such as draw sheet to prevent shear and friction?
300
reactive hyperemia
What is redness of skin due to dialation of superficial capillaries (pressure)?
300
reduces the skins resistance to other physical factors such as pressure or shear.
What is moisture?
300
moisture decreases resistance to to microorganisms and promotes skin breakdown
What is fecal/urinary incontinence?
300
mechanisms of wound healing
What is partial thickness wound repair and full-thickness wound repair?
300
air mattress, buddys for heals, turn every 2 HOURS, pilliows, dont massage
What is support surfaces/pressure reduction?
400
area of redness that turns lighter colored when touched
What is blanchable hyperemia?
400
malnutrition especially poor protein intake causes soft tissues to be susceptible to breakdown. generalized ill health and malnutrition
What is nutrition and cachexia?
400
notgoing to turn or can't feel area
What is decreased mental status/diminished sensation?
400
secondary intention example- pressure ulcers inflammatory response- last longer, about 3 days proliferative phase- key event- production of new tissue, occurs more quickly, blood flow and oxygen to wound so pack with wet to dry dressing so epithelial cells migrate there remodeling phase- can last up to a year, moist wet saline until healed
What is full thickness wound repair?
400
nutriton
What is maintain intake especially protein for tissue repair?
500
nonblanchable hyperemia
What is red and why try to do blanch test stays red color? if persist indicates tissue damage
500
infection and age
What is increases metabolic demands and there is a natural loss of dermal thickness with aging and increased metabolism of young children?
500
immunosuppression
What is chemotherapy, high dose of predisone, high dose of steriods (used for organ transplants)?
500
inflammatory response- not adding moisture, body heals wounds that heal by primary intention 2 process: 1) hemostasis- blood will clot, stop vasoconstrict 2) phagocytosis- cleaning it out, with macrophages, WBC will engulf microorganisms epidermal repair- in 24-72 hrs, epithelial proliferation, new epithelial cells dermal repair- epidermis thickens and anchors so can resume normal functioning, new wound is pink in color, dry and fragile certain wounds need normal moist evironment (primary intention)
What is partial thickness wound repair?
500
tell consequences of it if have protective spouse- may not let them MAKE SURE PHYSICIAN IS AWARE IF THEY REFUSE AND THEN DOCUMENT
What is patient/caregiver education?
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