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Pressure ulcers and wound careMedical-Surgical Nursing-7th edition

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Question Answer
_______ is indicated when a client has signs of cellulitis or sepsis. It is the quickest method of debridement.
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Surgical debridement
When skin is injured the _______ functions to resurface the wound and restore the barrier against infectious organisms.
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Soft yellow or white tissue in a wound is called _______ and needs to be removed before the wound can heal.
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When the skin is injured the _______ restores structural integrity and physical properties of the skin.
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Why is the skin in older adults more prone to tears?
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Thinning of underlying muscle and tissue; Less collagen; and Less elasticity.
Who are most at risk for pressure ulcer development?
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Decreased mobility, decreased sensory perception, fecal/urinary incontinence, and/or poor nutrition.
What 3 factors contribute to pressure ulcer development?
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Pressure intensity, pressure duration, and tissue tolerance.
You cannot stage an ulcer covered with _______.
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necrotic tissue
_______ is red moist tissue composed of new blood vessels, indication of a progression toward healing.
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Granulation tissue
Irrigation solution should be the same temperature as _______.
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body temp.
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Irrigation of an open wound requires _______ technique.
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What is the difference between black (PU) foam and white (PVA) foam (for V.A.C.)?
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Black = stimulates granulation and wound contraction. White = restricts granulation.
What conditions can be contraindications for heat therapy?
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Bleeding, inflammation like appendicitis, and cardio problems.
When is cold therapy contraindicated?
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Edematous tissue, decreases circulation (arteriosclerosis), neuropathy, and shivering.
What should you do prior to applying elastic bandages to a client's lower extremities?
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Elevate dependent extremities to enhance venous return. Apply before client sits or stands.
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