Question | Answer |
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 |
jhf | hgvh |