Pressure ulcers
Pressure ulcers can be caused by (4)
1. pressure
2. moisture
3. shearing forces
4. friction
13-14 on Braden risk assessment scale
Moderate risk
full thickness; epidermis, dermis and underlying subcutaneous tissue
Third degree burn
Burns (full thickness / 3rd and 4th degree), wounds, infection such as necrotizing fasciitis, skin cancer
Indications of skin transplant (graft)
T/F: When staging pressure ulcers, a patient can go from a stage 4 ulcer to a stage 3 ulcer?
False
Stage it: full thickness skin loss involving damage or loss of subcutaneous tissue; up to, but not through
Stage 3
9 or less on Braden risk assessment scale
Very high risk
Epidermis only; local pain and erythema
EX: sunburn
First degree burn
A tissue graft from a donor of a different species from the recipient
Xenograft
Frequent skin assessment, repositioning, pressure reduction, removal, and distribution; elimination of moisture
Preventative techniques for pressure ulcers
Stage it: nonblanchable erythema of intact skin
Stage 1
19-23 on Braden risk assessment scale
No risk
Epidermis and dermis, leaving only skin appendages
Dermal appendages: nails, hair, sebaceous glands, eccrine and apocrine sweat glands
Deep partial thickness --> Second degree burn
Same individual
Autograft
Percentage considered to be major burn injuries
20%
Stage it: full thickness skin loss with exposure of muscle, bone, or supporting structure
Stage 4
15-18 on Braden risk assessment scale
Mild risk
Full thickness and deeper tissue; epidermis, dermis and underlying subcutaneous tissue, tendons, muscle and bone
Fourth degree burn
Between individuals
Allograft
What degree burn may cause contractures when healing?
Deep partial thickness (2nd degree) and 3rd degree burns
Stage it: partial thickness skin loss involving epidermis or dermis
Stage 2
10-12 on Braden risk assessment scale
High risk
Epidermis and some dermis
Superficial partial thickness --> Second degree burn
Collagen scaffold used for burns
Artificial skin
Burns follows the rule of:
Nines