Definitions 1 - Wounds/PI
A break or opening into the skin.
What is Wound?
Mass of scar tissue; appears tumor-like.
What is Keloid scars?
3 factors that delays wound healing.
What are Nutritional deficiencies, Inadequate blood supply, Corticosteroids, Anemia, Smoking, Mechanical friction, Advanced age, Obesity, Diabetes, and poor general health?
What is Raynaud's Phenomenon?
Patient educated to _____, _____, and _____ to prevent episodes of Raynaud's Phenomenon.
Avoid extreme temperatures/wear appropriate clothing,
Avoid caffeine,
Not use tobacco products,
Not take vasoconstrictor drugs
Manage stress
Bands of scar tissue.
What is Adhesions?
Tissue loss extends to dermis.
What is depth of tissue loss - Partial thickness?
3 signs of infection in pressure injuries.
What is leukocytosis, fever, necrotic tissue, warm, painful, increased wound size, odor, or drainage?
Presents with intermittent claudication, paresthesia, thin, shiny, and taut skin in lower extremities.
What is Peripheral Artery Disease?
What are Leg-strengthening exercises, Graduated compression stockings, and Rest with limb elevation?
Persistent non-blanchable deep red, maroon, or purple discoloration.
What is Deep Tissue Pressure Injury?
Skin loss which cannot be repositioned to cover the wound bed.
What is Skin tear – Partial Skin Loss?
List the correct way of wound measurement.
What is measuring from head to toe, side to side, and depth of wound?
Presents with unilateral edema in lower extremity, 101° F fever, full sensation in thigh, and tenderness/pain upon palpation.
What is Venous Thromboembolism (VTE)?
3 areas of assessment status post peripheral artery bypass surgery for PAD.
What are skin color, temperature, capillary refill, presence of peripheral pulses distal to operative site, sensation/movement of extremity, and pain management.
Abnormal passage between organs or organ and skin.
What is Fistula formation?
Obscured full-thickness skin and tissue loss due to slough or eschar.
What is Unstageable Pressure Injury?
The 3 classifications of wounds.
What is surgical/nonsurgical, acute/chronic, and depth of tissue loss?
Presents with eczema, open wounds, 1+ edema, and brown leathery skin on bilateral lower extremities.
What is Chronic Venous Insufficiency (CVI) and Venous Leg Ulcers?
2 nonpharmacological and 2 pharmacological treatment options for VTE.
What are
Early and progressive mobilization, Graduated compression stockings, Intermittent pneumatic compression devices (IPCs).
Warfarin, Heparin, Enoxaparin (Lovenox), Argatroban, Dabigatran (Pradaxa), Fondaparinux (Arixtra), Rivaroxaba (Xarelto), Apixaban (Eliquis), Edoxaban (Savaysa).
Full-thickness skin loss with subcutaneous tissue visible.
What is Stage 3 Pressure Injury?
Partial thickness skin loss with exposed dermis. Wound bed is viable, pink/red, or moist.
What is Stage 2 Pressure Injury?
3 nursing interventions for treatment or prevention of wounds/PI.
What are wound care, nutritional support, pain management, control of other medical conditions, redistribution of pressure, possible surgery, relieve pressure, encourage patient to reposition/ambulate, do not turn patient onto skin with blanchable erythema, and do not massage inflammation, damaged blood vessels, or fragile skin?
Presents with heavy, achy feeling or pain after prolonged standing and relived by walking. Occasionally feels itchy, tingling, and cramp-like sensations.
What are Varicose Veins?
Patient diagnosed with Chronic Venous Insufficiency and Venous Leg Ulcers. The nurse educates the patient regarding activity guidelines and limb positioning which include _____, _____, _____, _____, and ______.
What are Avoid prolonged sitting or standing, Elevate legs above heart, Daily walking, Avoid trauma, and Daily foot and leg care?