Sample Quiz

what does it look like, what is causing it and how are we going to treat it

• poor circulation, no oxygen reaching that area, causing tissue damage

ischemia

• pressure occludes blood flow, causing tissue ischemia

• less prefusion and less blood flow and circulation to that area

• when you move the patient in one direction and the patients skin is stuck or moving in the other direction

cant feel the need to shift their weight or move

braden risk assessment scale

• sensory perception
• moisture
• activity
• mobility
• nutrition
• friction and shear

non blanchable erythema (redness) of intact skin

• no risk for infection because there is no opening in the skin

partial thickness skin loss with exposed dermis

full thickness skin loss

full thickness skin loss (muscle and bone)

obscured full thickness skin and tissue loss- depth unknown (covered in necrotic tissue)

persistent non-blanchable deep red, maroon or purple discoloration (possibility for tissue recovery)

occur when skin/tissues are subjected to sustained pressure or shear from medical devices or equipment

-remove devices as soon as medically feasible

• keep skin clean and dry underneath
• reposition patient or device to redistribute pressure/shear
• consider use of prophylactic dressing (cushioned dressing)
• think about the surface they are on (pressure reducing mattress)

disruption of the integrity and function of tissues in the body resulting from trauma or surgical intervention

skin is split, incised or cracked and underlying tissues are exposed to the environment (RISK FOR INFECTION)

skin surface intact but underlying tissues may be damaged (no risk for infection)

primary - skin edges are approximated secondary- wound left open until it fills with scar tissues (higher chance of infection)

moist and free of necrotic tissue and infection

• clear, watery plasma

thick, yellow/green/brown which indicates infection

pale, pink and watery

bright red, indicates active bleeding

bleeding from wound site

seperation of wound layers

protrusion of visceral organs through wound opening

partial thickness, skin is rubbed away (scraping your knee)

all layers of skin torn away skin flap: minor degloving: moderate amputation: major

from linear scratching

from tearing of soft body tissue, often irregular and jagged

usually caused by. a sharp pointy object such as a nail, animal teeth, usually does not bleed excessively, prone to infection

• from a projectile, look for entrance/exit wounds
• prone to infection
• underlying damage to soft tissue/organs

• elderly
• steriod use
• ICU patients
• Fluid overload

Signup and view all the flashcards

• removal of nonviable, necrotic tissue

rid the wound of source of infection, enable visualization of the would bed and provide a clean base for healing

wet-to-dry gauze dressing that pulls out dead (and healthy)tissue from the wound when it is removed

lysis of necrotic tissues by the WBCs and natural enzymes of the body by using dressing

• neg pressure wound therapy (would vac) used for ope draining wounds

topical preparations or sterile maggots that breakdown and digest or dissolve necrotic tissue

removal of dead tissue with a sharp instrument by a provider

• two surfaces that rub together which produces friction and heat
• friction causes skin breakdown which intitally becomes red and inflamed and potentially pruitic (itchy) and can ultimately develop fissures and erosions

• groin is the most commonly affected area but it can occur around the neck, in the axillae, under skin folds and between fingers and toes

a yeast which is normal flora of the skin. GI tract and genitourinary tract ( this can grow in a intertrigo)

• keep skin clean and dry
• light dusting of powder, not clumps
• anti inflammatory creams
• barrier ointment (very moist/incontinence contaminated folds)

patients on antibiotics, patients immunosuppressed, morbidly obese, diabetes

• need a medicated topical ointment
• if infection gets worse there is an oral medication

• infected hair follicle
• caused by bacteria or yeast
• painful, swollen, itchy
• it usually happens when a hair follicle is blocked or irritated by sweat and rubbing against sheets

• antibacterial soap, changing sheets more often, managing perspiration/moisture

varicella- zoster virus

a nerve pathway

• inflammation that occurs when urine or stool comes into contact with skin

very dry and peels

think about is it over a bony prominence, is the patient in contact with urine or stool

infection of skin and soft tissue

• most often is caused by bacteria that live on the skin
• bacteria only causes a problem is skin is torn, punctured or scratched

systemic (whole body) antibiotics topical treatment manage the drainage consider antimicrobial dressing elevation of extremity for edema management

caused by venous blood that are just sitting in the vein and not moving back to heart (valves aren't working)

• most likely see in the legs
• ulcer locations: typically just above malleolus, very painful skin is dry, inverted champange bottle apperance, thickened nails

compression dressings, moist wound care, steroid cream for stasis dermatitis/eczema, moisture skin, elevation, life-long compression

• not good arterial blood flow to that area
• tissues are not getting circulation that they need

revascularization, surgery that opens up artery

• amputation
• hyperbaric oxygen therapy (early stages)

• damage to the nerves where it becomes numb, skin becomes open and as they continue to walk on it it gets worse and worse
• would healing takes much longer in diabetic patients

callous, and underneath there is an ulcer

tunneling within the wounds that hold pockets of infection

sharp

if there is a neuropathic ulcer on your feet, there is a boot that can help distribute pressure

Signup and view all the flashcards