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