Understanding Pressure Injuries and Wound Healing PDF

Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 1. Wound Healing Differentiate among healing by primary, secondary, and tertiary intention. 2. Wound Healing Describe wound healing principles. P...

Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 1. Wound Healing Differentiate among healing by primary, secondary, and tertiary intention. 2. Wound Healing Describe wound healing principles. Principles 3. Nursing Process Explain the nursing process in caring for individuals expe- riencing a wound. 4. Factors Delaying Describe factors that delay healing or result in complica- Healing tions. 5. Pressure Injury Explain the etiology and clinical manifestations of pres- Etiology sure injury. 6. Braden Scale Discuss using the Braden Scale to assess for pressure injury risk. 7. Pressure Injury Identify measures used to prevent pressure injury devel- Prevention opment. 8. Pressure Injury Explain the nursing and collaborative management of Management pressure injury with or without infections of the integu- ment. 9. Pressure Injury A localized injury to the skin and/or underlying tissue due Definition to pressure. 10. Tissue Necrosis Cause tissue necrosis, usually over boney prominence. 11. Oxygenation in If tissue is under pressure against the bone are the cells Pressure Injury receiving oxygen? 12. Duration of Pres- Length of time pressure is exerted (duration). sure 13. Tissue Tolerance Ability of tissue to tolerate externally applied pressure, Factors influenced by age, density, collagen, and co-morbidities. 14. Shearing Force 1/6  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 Pressure exerted on the skin when it adheres or sticks to the bed linen and the skin layers slide in the direction of body movement. 15. Friction Two surfaces rubbing against each other: Sheet and skin when pulling a patient up in bed. 16. Moisture Excessive diaphoresis, urine, stool. 17. Pressure Ulcer Pressure Ulcers are graded and staged according to the Staging deepest area of tissue damage, from Stage 1 (minor) to Stage 4 (severe). 18. Slough Appearance: Stringy, yellow texture; dead tissue, a vascu- lar. 19. Eschar Black/brown necrotic tissue; a vascular; biologic cover. 20. Stage 1 Pressure Intact skin with non-blanchable redness; possible indica- Ulcer tors include skin temperature, tissue consistency, pain. 21. Stage 2 Pressure Partial-thickness loss of dermis; shallow open ulcer with Ulcer red pink wound bed; presents as an intact or ruptured serum-filled blister. 22. 2/6  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 Stage 3 Pressure Full-thickness skin loss involving damage or necrosis of Ulcer subcutaneous tissue that may extend down to, but not through, underlying fascia; the wound color includes yel- low. 23. Stage 4 Pressure Full-thickness loss can extend to muscle, bone, or sup- Ulcer porting structures; bone, tendon, or muscle may be visible or palpable. 24. Unstageable Full thickness tissue loss in which the base of the ulcer Pressure Ulcer is covered by slough and/or eschar; the depth and stage cannot be determined until the slough and eschar are removed. 25. Clinical Manifes- Signs/Symptoms include leukocytosis, fever, increased ul- tations of Wound cer size, odor, or drainage, necrotic tissue, and pain. Infection Untreated ulcers may lead to cellulitis, chronic infection, sepsis, and possibly death 3/6  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 26. Braden Scale To- Total Score of 23 possible; 18 or less indicates High Risk tal Score for skin breakdown. 27. Tissue Injury Look for areas of skin darker than surrounding skin; may in patients with appear with red, blue, or purple hues in darker skin tones. deep pigmenta- tion 28. Skin Tempera- Assess skin temperature using your hand; an ulceration ture Assessment may feel warm initially, then become cooler. 29. Nursing Problem Impaired Skin Integrity related to skin breakdown sec- ondary to pressure ulcer, as evidenced by pressure sore on the sacrum. 30. Risk for Impaired Risk for impaired skin integrity related to immobility as Skin Integrity evidenced by prolonged sitting. 31. Impaired Skin In- Skin infection evidenced by open sore. tegrity 32. Osteomyelitis Bone infection from bloodstream or nearby tissue. 33. Nutritional Defi- Lack of nutrients impairs tissue healing. ciencies 34. Corticosteroid Inhibit inflammatory response, impair healing. Drugs 35. Diabetes Mellitus Elevated blood glucose increases infection risk. 36. Anemia Reduced oxygen delivery to cells and tissues. 37. Wound Care Prevent infection and promote healing. 38. Pressure Relief Reduce pressure on vulnerable skin areas. 39. Debridement Removal of necrotic tissue from wounds. 40. Primary Intention Wound healing with neatly approximated edges. 4/6  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 41. Secondary Inten- Healing with extensive tissue loss and exudate. tion 42. Tertiary Intention Delayed suturing after infection resolution. 43. Complications of Issues like dehiscence and hypertrophic scars. Healing 44. Wound Measure- Measured in centimeters: length, width, depth. ments 45. Negative-Pres- Suction removes drainage, speeds healing. sure Wound Therapy 46. Culture and Sen- Identifies organisms for effective antibiotic treatment. sitivity 47. Levine's Tech- Method for obtaining wound culture samples. nique 48. Psychological Concerns about scars and odor during care. Implications 49. Caloric Intake Increased calories and protein for healing. 50. Enteral Feedings Nutritional support via feeding tubes. 51. Surgical Debride- Surgical removal of necrotic tissue. ment 52. Moist Wound Keeps ulcer bed moist for better healing. Healing 53. Skin Care Pre- Avoid moisture and pressure on skin. vention 54. Positioning De- Use pillows and protectors to relieve pressure. vices 5/6  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 55. Daily Weight Track weight to assess nutritional status. Monitoring 56. Healing Process Includes regeneration and repair of tissues. 57. Healing Stages Initial, granulation, maturation phases of healing. 58. Exudate Manage- Control drainage to promote healing. ment 6/6