fundamentals chp 48 integrity and wound care

pressure intensity

how much pressure is applied to capillaries

tissue ischemia

occlusion of capillaries over a period of time

blanching

when normal red-tones of the skin are absent

stage 1

intact skin with non blanchable redness

stage 2

partial-thickness skin loss involving epidermis, dermis, or both. shallow/open ulcer. pink would bed

stage 3

full thickness tissue loss with visible fat

stage 4

full thickness tissue loss with exposed bone, muscle, or tendon

unstageable

Full-thickness skin or tissue loss. depth unknown. remove slough or eschar to see wound

primary intention

smooth and edges are approximated

secondary intention

jagged, uses scar tissue to fill wound

transparent dressing

traps moisture

hydrocolloid dressing

forms a gel as secretions are absorbed

hydrogel

hydrate & absorb

foam or alginate

used for lots of drainage