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Terms in this set (159)
what are 6 risk factor sensory perception, moisture, mobility, activity,
components of Braden nutrition, and shear/friction
Scale for pressure ulcer?
What is the name of the NPUAP (national pressure ulcer advisory panel)
organization that
developed the pressure
ulcer staging?
pathological effect of tissue tolerance, duration of pressure, and intensity of
excessive pressure on soft pressure
tissue can be attributed by
3 factors? what are they?
what are the extrinsic increase in moisture, friction and shearing
factors that impact
pressure ulcers?
friction alone causes only superfical abrasion, but with
gravity it plays a synergistic effect leading to shearing.
how does friction play a
When gravity pushes down on the body and
role in shearing which
resistance (friction) between the patient and surface is
eventually leads to
exerted, shearing occurs. because skin does not
pressure ulcer?
freely move, primary effect of shearing occurs at the
deeper fascial level.
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what are the intrisinc nutritional debilitation, advanced age, low BP, stress,
factors of pressur ulcers? smoking, elevated body temperature
dermoepidermal junction flattens, less nutrient
exchange occurs, less resistance to shearing, changes
Aging skin undergoes
in sensory perception, loss of dermal thickness,
what elements affecting
increased vascular fragility; ability of soft tisuse to
risk for pressure ulcer?
distribute mechanical load w/out comprosing blood
flow is impaired
when pressure is applied to the erythematic area skin
becomes white (blanched), but once relieved,
What does nonblanching
erythema returns -indicating blood flow; however in
erythema indicate in the
nonblanching erythema, skin does not blanche-
skin r/t PU?
indicating impaired blood flow-suggesting tissue
destructon
why does sitting in a chair deep tissue injury or PU is likely to occur sooner
pose more of a risk in skin sitting down because tissue offloading over boney
break down than lying? prominences is higher
purple or maroon localized area of discolored intact
skin skinor blood filled blister; may be preceded by
Describe what you will
painful, firm, mushy, or boggy; skin may be warmer to
see in deep tissue injury?
cooler in adjacent tissue. In dark skin, thin blister or
eschar over a dark wound bed may bee seen
Intact skin with nonblanchable redness of localized
area. Will not see blanching in dark skin, but changes
Describe stage I pressure
in skin tissue consistency (firm vs boggy when
ulcer?
palpated), sensation (pain), and warmer or cooler
temperature may differ from surrounding area
partial-thickness wound where epidermis and tip of
Describe stage II pressure dermis is lost with red-pink wound bed w/out slough.
ulcer? may also present as intact or open/ruptured serum -
filled blister
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full-thickness wound where both epidermis and
dermis is lost and subcutaneous tissue may be visible,
Describe stage III but deeper structures such as muscle, bone, and
pressure ulcer? tendon are not exposed; slough my be present but it
doesn't obscure depth and tunneling and
undermining may be present
full-thickness wound with exposed bone,tendon, and
muscle; slough or eschar may be seen in some parts
Describe stage IV
of the wound bed. you will often see tunneling and
pressure ulcer?
undermining. Osteomyelitis may be dxed at this stage,
since bone is palpable
Describe unstageble full-thickness wound where base of the ulcer is
ulcers? covered by slough and/or eschar, obscuring depth
when it's stable with dry, adherent, and intact w/out
When should eschars not
erythema on the heel; this serves as the body's natural
be removed?
cover and should not be removed.
Therapeutic function of immersion and envelopement
pressure distribution is
accomplised by what 2
factors?
depth of penetration or skining into surgace allowing
Define immersion? pressure to be spread out over surrounding area
rather than directly over boney prominence
is the ability of support surface to conform to
Define envelopement? irregularities without causing substantial increase in
pressure
this occurs when depth of penetration or sinking is
what is bottoming out? excessive, allowing increased pressure to concentrate
over boney prominences
weight, disproportion of weight and size such as
what factors contribute to
amputation, tendency to keep HOB >30 degrees,
bottoming out?
inappropriate support surface settings
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