-
3 factors that contribute to pressure ulcer development
pressure intensity, pressure duration, tissue tolerance
-
risk factors for pressure ulcers
impaired sensory perception, alterations in LOC, impaired mobility, shear, friction, moisture
-
What kind of light to use when assessing darker skin?
halogen/ natural lighting
-
Stage I pressure ulcer
intact skin with nonblanchable redness
-
Stage II presssure ulcer
Partial-thickness skin loss involving epidermis, dermis, or both
-
Stage III pressure ulcer
Full-thickness skin loss with visible fat
-
Stage IV pressure ulcer
Full-thickness skin loss with exposed bone, muscle, or tendon
-
What indicates a patient is at risk for pressure ulcers on the Norton's scale?
14 or less
-
What score indicates a patient is at risk for pressure ulcers on the Braden scale?
- 18 or less
- lower scores means greater risk
-
Define a wound
disruption in the integrity and function of tissues in the body
-
Healing stages of Wounds
- Inflammatory (1-3days)
- Proliferative(3-24days)
- Remodeling(up to 1yr)
-
When is the greatest risk for hemorrhages?
24-48hrs after surgery
-
define evisceration
total edge seperation with organ protrusion
-
define dehiscence
partial seperation of edges
-
wet to dry dressing
a form of mechanical debridement
-
hydrocolloid dressing
protects the womb from surface contamination
-
wet to wet dressing
topped with dry..to keep moist for healing
-
hydrogel
maintains a moist surface to support healing
-
wound V.A.C.
uses negative pressure to support healing
-
principles of cleansing wound (5)
- start in middle and move outwards
- never go back to middle with same swab
- usually done 3 times
- may irrigate to flush debris
- assess for tunnel or ledge
-
define debridement
- remove necrotic tissue
- methods used depends on individual's factors; chemical,, mechanical, autolytic, surgical
-
kidneys
remove waste from the blood to form urine
-
ureters
transport urine from the kidneys to the bladder
-
bladder
reservoir for urine until the urge to urinate develops
-
urethra
urine travels from the bladder and exits through the urethral meatus
-
normal urine that indicates you are well hydrated should be..
pale yellow, clear
-
approx bladder capacity
600 ml
-
when can a person "feel" like they need to urinate?
150-200 ml
-
urinary retention
- an accumulation of urine due to the inability of the bladder to empty . overflow can occur
- goes frequently ...can see in post-op pts
-
UTI
urinary tract infection; may occur from procedure or catherization. 40% of HAI's. women more often than men
-
urinary diversion
diversion of urine to new external opening (nephrostomy, ileal loop, continent diversion)
-
urinary incontinence
- involuntary leakage of urine, continuous or intermittent..more common in older age
- but not a NORMAL aging process
-
kegal exercises
contraction on the pelvic floor to help improve urinary muscles
-
-
catherization
- insertion of a catheter the the urethra into the bladder to provide a continuous flow of urine
- insertion; need order, strict sterile technique
|
|
