Integumentary Word Scramble
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Question | Answer |
Stage I Pressure Ulcer | skin intact; changes in color, temperature, stiffness, or sensation |
Stage II Pressure Ulcer | partial-thickness skin loss (epidermis and/or dermis); superficial abrasion, blister, or shallow crater |
Stage III Pressure Ulcer | full-thickness skin loss; necrosis of subcutaneous tissue & underlying fascia; deep crater w/ or w/o undermining of adjacent tissue |
Stage IV Pressure Ulcer | full-thickness skin loss; tissue necrosis, damage to muscle, bone, or support structures |
(Bony Prominences Associated with pressure injuries) in Supine | Occiput---Scapula: spine, inf. angle---(Bony Prominences Associated with pressure injuries) Vertebral spinous processes---Humerus: medial epicondyle---Posterior iliac crest---Sacrum---Coccyx |
(Bony Prominences Associated with pressure injuries) in Prone | Forehead---Acromion process (ant. portion)---Ant. head of humerus---Sternum---ASIS---Patella---Dorsum of foot |
(Bony Prominences Associated with pressure injuries) in Sidelying | Ears---Acromion process (lateral portion)---Lateral head of humerus---Gr. Trochanter---Fibular head---Lateral & Medial malleoli |
(Bony Prominences Associated with pressure injuries) in Sitting (Chair) | Spine of Scapula---Vertebral spinous processes---Ischial tuberosity |
Pressure ulcers form because... | pressure to soft tissue that exceeds normal capillary pressure of the local circulation |
8 Factors contributing to pressure ulcers: | shear, friction, heat, moisture, medication, muscle atrophy, malnutrition, debilitating medical conditions |
Neuropathic ulcers | 2° complication associated with combination of ischemia & neuropathy. Seen with Diabetes. |
Where are neuropathic ulcers usually located? | plantar surface of foot, beneath met. heads |
Describe a neuropathic ulcer wound. | prominent callus rim with good granulation tissue & little or no drainage. |
Other key facts about neuropathic ulcers | usually painless (altered sensation); pedal pulse diminished or absent; distal limb shiny & cool to the touch; periwound skin is dry or cracked |
Arterial insufficiency ulcers | occur 2° to ischemia from inadequate circulation of oxygenated blood; often due to complicating factors such as atherosclerosis |
Location of Arterial Ulcers | lower 1/3 of leg: toes, web spaces, lateral malleolus |
Appearance of Arterial Ulcers | Smooth edges, well defined, deep, NO granulation tissue |
Pain Associated with Arterial Ulcers | Severe |
Pedal Pulse with Arterial Ulcers | Diminished or absent |
Edema with Arterial Ulcers | Normal (localized) |
Skin temperature with Arterial Ulcers | Decreased |
Tissue Changes with Arterial Ulcers | Thin & shiny; hair loss; yellow nails |
Leg elevation with Arterial Ulcers | INCREASES pain!! |
Venous insufficiency ulcers | occur 2° to inadequate functioning of the venous system resulting in inadequate circulation & eventual tissue damage & ulceration |
Location of Venous Ulcers | proximal to medial malleolus |
Appearance of Venous Ulcers | Irregular shape; shallow |
Pain associated with Venous Ulcers | mild to moderate |
Pedal Pulse with Venous Ulcers | Normal |
Edema with Venous Ulcer | INCREASED |
Skin Temperature with Venous Ulcer | Normal |
Tissue Changes with Venous Ulcer | Flaking, dry skin, brownish discoloration |
Leg Elevation with Venous Ulcer | decreases pain |
Intervention for Arterial Insufficiency Ulcers | Cleansing, Rest, Reducing risk factors, & Limb Protection |
General Recommendations for Arterial Insufficiency Ulcers | 1)Wash/dry feet thoroughly 2)Avoid unnecessary leg elevation 3)Inspect legs/ feet daily 4). Wear appropriately sized shoes w/seamless socks 5). Use bandages as necessary & avoid any unnecessary pressure 6). Avoid using heating pads or soaking feet in hot |
Intervention for Venous Insufficiency Ulcers | Cleansing, Compression to control edema |
General Recommendations for Venous Insufficiency Ulcers | 1). Elevate legs above heart when resting or sleeping 2). Attempt active exercise including frequent ROM 3). Inspect legs & feet daily 4). Wear appropriately sized shoes with clean, seamless socks 5). Use bandages as necessary & avoid scratching or other |
How often should bed-bound patients be turned to prevent pressure ulcers? | every 2 hours |
Created by:
s1234
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