Pressure Ulcers
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| a protein substance that adds strength to a healing wound | collagen
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| chronic wound, caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. | Pressure Ulcer(decubitus ulcers, pressure sores, and bedsores)
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| to lose color (test the skin integrity of the circulation performed by applying and then quickly releasing pressure. The "blanched" area should regain pink color quickly OR failure to do so suggest impaired blood flow to area). | blanching
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| inadequate blood supply to tissue | tissue ischemia
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| an oxygen deficiency to the tissues | tissue hypoxia
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| an area of hardened tissue | induration
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| skin flushes bright red when pressure to area is relieved; extra blood rushes to area to compensates for ischemic period | normal reactive hyperemia
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| when redness does not disappear quickly; tissue damage has occurred | abnormal reactive hyperemia
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| black leathery covering comprised of nectrotic tissue ( dead cells) and plasma proteins. | eschar
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| removal of devitalized tissue; allows wound to heal and removes the medium for bacterial growth; 4 types: sharp, mechanical, enzymatic and autolytic | debridement
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| unrelieved pressure that compromising blood flow resulting in ischemia (inadequate blood supply) in underlying tissue | cause of pressure ulcer
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| alter skin characteristics or O2 delivery capabilities: nutrition, age, circulation, underlying health status(mobility, impaired sensation( spinal cord injury, coma, stroke), malnutrition, aging...) | intrinsic
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| mechanical force from dragging across coarse surface | friction
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| pressure exerted against skin parallel to body surface, epidermal layer slides over dermis causing damage to vascular bed | shearing
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| macerates (soften by sleeping in fluid) the skin ( often, urine and feces and MOISTURE decreases amt. of pressure required to produce ulceration. | exposure to moisture
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| extensive tissue loss edges not approximated; heal from inner layer to outer layer by granulation; ( ex. pressure ulcer, infected wound). | secondary intention
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| delayed primary closure, initially heal 2nd intention, then suturing; ( ex. infected surgical wound). | tertiary intention
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| "cleansing"- hemostasis and inflammation (1-5 days) | inflammatory
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| "regeneration"- ( day 5-21); fill defect and resurface skin; collagen forms; granulation occurs. | proliferation
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| "epithelialization" (2-3 week) till wound heals); scar tissue forms and wound strengthens. | maturation
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| ^ protein ^calories | nutritional needs for preventing impaired skin integrity
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| inspection, check pressure points, meticulous skin care with bath (mild soaps, rinse thoroughly); incontinent care; linen change as needed | skin care needed for impaired skin integrity
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| HOB 30 degrees to minimize pressure and shear | frequent positioning turn Q 2 hrs ( for impaired skin integrity)
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| wound dressings that keep wounds moist | hydro colloids
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| clear and semi permeable dressings | transparent films
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| dressings used on wounds with large amounts of exudate | absorption dressings
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| jelly like consistency ( granules, sheets, or gels)- no adherence to wound bed | hydrogels
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| localized injury to the skin and/or underlying tissue usually over a bony prominence | pressure ulcer
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| avoidable and non avoidable | two types of pressure ulcers
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| majority of pressure ulcers are located | pelvis and heels
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| pressure blocks blood flow leads to inflammation leads to tissue death leads to tissue necrosis | cellular level of a pressure ulcer
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| intact skin with non-blanchable redness of localized area usually over a bony prominence dark pigmented skin may not have visible blanching; its color may differ from the surrounding area | stage 1
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| partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough may also present as a intact or open or ruptured serum-filled blister | stage2
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| full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed slough may be present but does not obscure the depth of tissue lossmay include undermining and tunneling | stage 3
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| full thickness tissue loss with exposed bone, tendon, or muscle slough or eschar may be present on some parts of the wound bed often include undermining and tunneling | stage 4
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| cannot see the base of the wound full thickness tissue loss in which the base of the ulcer is covered by: slough(yellow, tan, gray, green, or brown) and/or eschar(tan, brown, or black) | unstageable( cannot see the base of the wound)
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| purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear | suspected deep tissue injury
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| minimal tissue loss, approximated edges; Ex. clean surgical incision) | primary intention
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