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AH- CH 48

Adult Health I

wound drainage: clear, watery plasma serous
wound drainage: thick, yellow, green, tan, or brown purulent
wound drainage: pale, red, watery: mixture of clear and red fluid serosanguineous
wound drainage: bright red: indicates active bleeding sanguineous
hyperemia redness
occurs when the normal red tones of the light-skinned client are absent blanching
3 pressure-related factors to pressure ulcer development 1. pressure intensity 2. pressure duration 3. tissue tolerance
why should you avoid using a florenscent light when assessing dark skinned pt? b.c it makes blue tones
what are risks for pressure ulcer development? impaired sensory perception, impaired mobility, alteration in LOC, shear, friction, moisture
intact skin with nonbla nchable redness of a localized area stage 1 pressure ulcer
partial-thickness skin loss involving the epidermis or the dermis or both--superficial and presents as a abrasion, blister, or shallow crater stage 2 pressure ulcer
full-thickness tissue loss, subq fat may be visible--may include undermining and tunneling stage 3 pressure ulcer
full-thickness tissue loss with exposed bone, muscles, or tendons--often includes tunneling and undermining stage 4 pressure ulcer
red moist tissue composed of new blood vessels--reps healing granulation tissue
stringy substance attached to wound bed that is either soft yellow or white slough
black or brown necrotic tissue in the wound bed eschar
trauma or surgical incision wound acute
vascular compromise, chronic inflammation or repetitive insults to the tissue chronic
wound that is closed primary intention
wound edges are not approximated secondary intention
wound left open for several days, then wound egdes are approximated tertiary intention
wounds that are contaiminated and require observation for signs of infammation tertiary intention
pressure ulcers, surgical wounds that have tissue loss secondary intention
surgical incision, wound that is sutured or stapled primary intention
what are the 3 componets in the healing process of partial-thickness wounds 1. inflammation response 2. epithelial proliferation and migration 3. reestablishment of the epidermal layers
what are the 3 componets in the healing process of full-thickness wounds 1. inflammation process 2. proliferation 3. remodeling
is a localized collection of blood underneath the tissue hematoma
is the partial or total seperation of wound layers dehiscence
protrusion of viseral organs through a wound opening evisceration
is an abnormal passage between 2 organs or between an organ and the outside of the body fistula
is a protein formed from amino acids aquired by fibroblasts from protein ingested in food collagen
necessary for synthesis of collagen vit C
reduces the negative effect of steroids on wound healing vit A
is necessary for epitheliazation and collagen synthesis zinc
necessary for collagen fiber linking copper
provide the material needed to support the cellular activity of wound healing calories
biochemical indicators of malnutrition serum proteins
reflects what protein the pt has ingested, absorbed, digested, and metabolized prealbumin
is superficial with little bleeding and is considered a partial-thickness wound abrasion
bleeds more profusely, depending on the wound's depth and location laceration
wounds bleed in realtion to the depth and size of the wound puncture
norton scale scores what 5 things? phy condition, mental condition, activity, mobility, and incontinence
Braden scale scores what 6 things? sensrpy perception, moisture, activity, mobility, nutrition, and friction/shear
nortons scale range? 5-20
bradens scale range? 6-23
risk for pressure ulcer on norton scale is ___ 14
risk for pressure ulcer on braden scale is ___ 18
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Created by: TayBay15