integ4 ulcers
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| show | Unrelieved pressure deprives the tissues of oxygen which causes ischemia, subsequent cell death, and tissue necrosis
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| Pressure Ulcer | show 🗑
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| show | Impaired cognition, poor nutrition, altered sensation, incontinence, decreased lean body mass, and infection contribute to the development of a pressure ulcer
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| show | is the largest organ within the body and consists of the dermal and epidermal layers, hair follicles, nails, sebaceous glands, and sweat glands.
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| Each layer is stratified | show 🗑
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| show | is known as the true skin, is well vascularized, and is characterized as elastic, flexible, and tough.
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| show | is avascular and consists of the outermost layer of skin.
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| prominences Supine: | show 🗑
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| show | Forehead, anterior portion of acromion process, anterior head of humerus, sternum, anterior superior iliac spine, patella, dorsum of foot
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| show | Ears, lateral portion of acromion process, lateral head of humerus, lateral epicondyle of humerus, greater trochanter, head of fibula, lateral malleolus, medial malleolus
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| prominences Sitting (Chair): | show 🗑
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| show | An observable pressure related alteration of intact skin whose indicators as compared to an adjacent or opposite area on the body may include changes in skin color, skin temperature, skin stiffness or sensation.
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| Stage II | show 🗑
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| Stage III | show 🗑
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| show | A full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule).
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| show | secondary to ischemia from inadequate circulation of oxygenated blood often due to complicating factors such as atherosclerosis
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| show | secondary to inadequate functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration.
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| Pressure ulcers, often called decubitus ulcers, | show 🗑
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| show | shear, moisture, heat, friction, medication, muscle atrophy, malnutrition, and debilitating medical conditions.
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| show | usually associated with a combination of ischemia and neuropathy
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| Most often neuropathic ulcers are associated with | show 🗑
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| show | The wound has good granulation tissue and little or no drainage. Patients rarely report pain with neuropathic ulcers in part due to altered sensation.
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| show | Pedal pulses are most often diminished or absent.
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| show | The distal limb may appear to be shiny and appear somewhat cool to touch. The periwound skin often appears to be dry or cracked.
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| Factors Influencing Wound Healing | show 🗑
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| show | A decreased metabolism in older adults tends to decrease the overall rate of wound healing.
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| Factors Influencing Wound Healing Illness: | show 🗑
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| show | An infected wound will impact essential activity associated with wound healing including fibroblast activity, collagen synthesis, and phagocytosis.
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| Factors Influencing Wound Healing Lifestyle: | show 🗑
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| show | There are a variety of pharmacological agents that can negatively impact wound healing. Medications falling into this category include steroids, anti-inflammatory drugs, heparin, antineoplastic agents, and oral contraceptives. Undesirable physiologic effe
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| show | An abrasion is a wound that occurs from the scraping away of the surface layers of the skin, often as a result of trauma.
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| show | A contusion is an injury in which the skin is not broken. The injury is characterized by pain, swelling, and discoloration.
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| Hematoma: | show 🗑
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| Laceration: | show 🗑
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| show | A penetrating wound is a wound that enters into the interior of an organ or cavity.
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| Puncture: | show 🗑
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| show | An ulcer is a lesion on the surface of the skin or the surface of a mucous membrane, produced by the sloughing of inflammatory, necrotic tissue.
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| Red-Yellow-Black System Description Red | show 🗑
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| Red-Yellow-Black System Red Goals | show 🗑
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| show | Moist yellow slough
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| show | Debride necrotic tissue; absorb drainage
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| show | Black, thick eschar firmly adhered
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| show | Debride necrotic tissue
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| show | Lower one-third of leg, toes, web spaces (distal toes, dorsal foot, lateral malleolus)
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| show | Smooth edges, well defined; lack granulation tissue; tend to be deep
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| show | Severe pain
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| show | Diminished or absent
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| Arterial Ulcers edema | show 🗑
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| show | Decreased
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| show | Proximal to the medial malleolus
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| show | Irregular shape; shallow
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| show | Normal
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| Venous Ulcers | show 🗑
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| show | Increased
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| show | increases pain
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| Arterial Ulcers tissue changes | show 🗑
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| Venous Ulcers Leg elevation | show 🗑
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| show | Flaking, dry skin; brownish discoloration
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Created by:
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