301 Test 2 part 3 Flashcards
a small red or purple spot caused by bleeding into the skin.
Petechaie
(Melanoma) ___ cell carcinoma-most common doesn’t usually spread (sun)
Basal
___ cell carcinoma- more serious than basal. Travel to lymph odes and thoughout the body(sun)
Squamous
Moisture: diaphoresis occurs w ___ or decrease in __ __
thyrotoxicosis
or
decrease in tissue perfusion
very thin, shiny skin (atrophic) occurs w __ insufficiency
arterial
Edema: most evident in dependent areas, feet, ___, sacral areas
ankles
blotches in the skin that Jen had
vitiligo
circular lesions that begin in the center and spread to the periphery (i.e. ringworm, tinea)
Annular
lesions that run together
Confluent
distinct, individual lesions that remain separate
Discrete
cluster of lesions (i.e. vesicles of contact dermitis)
Grouped
lesions take form of a scratch, streak, line or stripe
Linear
lesions tatke a linerar arrangement along a nerve route (herpes zoster-shingles)
Zosteriform
besides destruction of skin, a defining characteristic of impaired skin integrity is
Invasion of body structures
Pressure compresses underlying tissue, hindering ___ flow and nutrient supply
blood
high risk areas for pressure ulcers (mostly bony prominences)
sacrum, trochanter, ears, heels, knees, iliac crest, shoulder, scapula
a narrow channel of tissue loss that can extend in any direction away from the wound through soft tissue and muscle.
tunnel
may result in dead space which can complicate wound healing.
tunnel
refers to tissue destruction underneath intact skin at the wound edge.
Undermining
Wound edges are not attached to the wound
base. Rather, skin edges overhang the periphery of the wound.
necrotic tissue. Usually yellow or tan and slimy
Slough
DTI (deep tissue injury) is most common on
sacrum, coccyx, and heels
Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Unstagable
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage I
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage II pressure ulcers may also present as an intact or open/ruptured serum-filled or serosangineous-filled blister.
Stage 2
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. Stage III pressure ulcers may include undermining and tunneling
Stage 3
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. These ulcers often include undermining and tunneling
Stage 4
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Suspected deep tissue injury
oder of Wound healing
Inflammation
Proliferation
Maturation
which phase (inflammation, Proliferation, Maturation), hemostasis is established
inflammation
which phase (inflammation, Proliferation, Maturation), Bacteria, devitalized tissue and other debris are ingested by phagocytes and removed
inflammation
which phase (inflammation, Proliferation, Maturation), new tissue forms (granulation and epithelialization) and the wound contracts
Proliferation
which phase (inflammation, Proliferation, Maturation), scar tissue is remodeled and strengthened
Maturation
Formation of collagen and capillaries in full thickness wounds from surrounding connective tissue. Appears as beefy red tissue in the wound bed
Granulation
Appears clinically as tissue that is thin, pearly or silvery and shiny
Epithelialization
Seen clinically as a reduction in wound depth and size
Wound contraction
in wound healing, The maturation phase may last for one __ or longer.
year
a rash of purple spots on the skin caused by internal bleeding from small blood vessels
purpura
a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.
ecchymosis
Thin, shiny skin, Decreased or absent skin hair, and pain are associated with
arterial ulcer
Associated Wound Characteristics
Minimal exudate
Pale wound bed; necrotic tissue may cover the wound
Well defined wound margins
arterial ulcer
Risk Factors
Older age
Previous history of venous disease or thrombophlebitis
Female
Pregnancy
Obesity
Occupation that involves standing for a long period
Venous ulcers
Venous ulcers location
Between the knee and the ankle
Usually between the lower calf and ankle in the area covered by a sock
Associated Skin Characteristics Hyperpigmentation of lower calf and ankle skin from hemosiderin staining Firm/hardened skin Dry scaly skin; may be itchy Edema
Venous ulcers
Associated Wound Characteristics
Often shallow
Irregular margins
Drainage
Venous ulcers
Treatment
Compression therapy often with multi layer wraps to reduce edema (una boot)
Venous ulcers
Treatment
Dressings such as alginates and foams to absorb drainage and exudates
Avoid moisture
Venous ulcers
Contributing causes:
Sensory, motor, and autonomic neuropathy
Peripheral vascular disease with poor microvascular circulation
Repetitive trauma, unperceived pressure, or friction/shear
Poor control of blood glucose levels
Diabetic ulcers
Wound Location
Usually on metatarsal head, top of toes, and foot
Diabetic ulcers
Associated Skin Characteristics Dry, cracked skin Warm skin Decreased sensation (neuropathy) Charcot's foot
Diabetic ulcers
Associated Wound Characteristics
Regular wound margins
Callus around wound
Diabetic ulcers
Recommended nutritional intake for the prevention of pressure ulcers is a minimum of __ to 35 kcal/kg body weight/day and __ to 1.5g/kg/day protein
30 and 1.25
Pressure ulcer management, transparent dressing (maybe)
1
Pressure ulcer management, Don’t massage. Turning, hydration, nutrition
1
Pressure ulcer management, If clean: hydrogel to provide moist environment w hydrocolloid dressing (3-7 days)
2
Pressure ulcer management, If clean: hydrogel, foam dressing, alginate dressing for excessive drainage, gauze
3
Pressure ulcer management, If clean: hydrogel, alginate for drainage, gauze, growth factors
4
Pressure ulcer management, if stable leave and maintain
If not stable, may use enzymatic ointment, or debridment may be needed
Eschar
Pressure ulcer management, Debridment, enzymatic ointment, cover w hydrocolloid for autolytic debridment
Necrotic
an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea
Cheyne-Stokes respiration
an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.
Biot’s respiration
he abnormal transmission of sounds from the lungs or bronchi
Bronchophony
an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis.
Egophony
a clinical test typically performed during a medical physical examination to evaluate for the presence of lung consolidation, which could be caused by cancer (solid mass) or pneumonia (fluid mass).
Whispered pectoriloquy
Forced expiratory time
Pulse oximeter
6-Minute distance walk
Measurement of pulmonary function status
a condition in which a person’s breastbone is sunken into his or her chest
Pectus excavatum
a breastbone (sternum) and rib cartilage deformity that causes the chest to bow outward
Pectus carinatum
resp gradually increase in rate and depth then decrease. Lasts vron 30-45 seconds w periods of apnea.
Cheyne-Stokes respiration
Occurs normally in infants and aging persons during sleep. May see w chg, renal failure, meningitis, drug overdose, increased intracranial pressure.
Cheyne-Stokes respiration
similar to cheyne stokes except pattern is irregular. Seen w head trauma, brain abscess, heatstroke, spinal meningitis and encephalistis
Biots
a palpable vibration produced during breathing caused by partial airway obstruction. The obstruction can be due to mucus or other secretions in the airway
Rhonchial fremitus
palpable vibration of the wall of the thorax caused by friction between the parietal and visceral pleura of the lungs
Pleural friction fremitus
percussing the lungs, hyper resonance means too much
air (emphysema or pneumothorax)
percussing the lungs, dull sound means the density is too
high (pneumonia, atelectasis, tumor)
tympany is aka
hyper resonance
Best time for BSE is after the
menstrual period
Amount of blood ejected from the left ventricle each minute
Cardiac Output
End diastolic pressure
Preload
Resistance to left ventricular ejection
Afterload
Amount of blood ejected from the left ventricle with each contraction
Stroke Volume
the amount of air exhaled in a normal breath
Tidal volume
Hypovolemia
Increased metabolic rate
Factors Affecting Oxygenation
Diaphoresis, dyspnea Headache upon wakening Use of accessory muscles Restlessness Somnolence Tachycardia Visual disturbances Acute/chronic Abnormal ABG Abnormal breathing pattern: rate, depth, rhythm Abnormal skin color Confusion Decreased/increased CO2 or O2
S&S of IGE
Barrel chest Clubbng Polycedthemia vera Increased RR Cough Wheezing Changes in ABG blue bloater and pink puffer
Chronic gas exchange problems: S&S
Dyspnea Management: Humidification is necessary for clients receiving more than _ L/minute of oxygen
4
Used when the client can cough effectively but is not able to clear secretions
Oropharyngeal and nasopharyngeal
Used when the client is unable to manage secretions
Orotracheal and nasotracheal
chronic disorder that can result in enlarged and misshapen bones
Paget’s disease of bone (osteitis deformans)
an extremely rare syndrome that results when the anterior pituitary gland produces excess growth hormone
Acromegaly
crutch walking: lead with affected leg when going __ stairs
up
crutch walking: lead with unaffected leg when going __ stairs
down
Clean wounds are uninfected and have minimal
inflammation
surgical incisions that enter the GI, respiratory, or GU tract: c__ c__ wounds
clean-contaminated wounds
___ wounds have a major break in asepsis but are not necessarily infected
contaminated
type of wound that extends through the epidermis but not through the dermis
partially thickness wound
type of wound that extends into the sub q and beyond
full thickness wound
promotes granulation tissue, reduces edema, removes exudate and infectious material
negative pressure wound therapy
silver dressings are used to control
bacteria
Electrical stimulation promotes
cell growth
stimulates growth of blood vessels and assists WBC
hyperbaric oxygen therapy
wound care that’s indicated for diabetic wounds and other nonhealing wounds free of necrotic tissue
tissue growth factors
wound care that stimulates movement of fluid of cells and helps with debridement
ultrasound
If a wound is necrotic dont __ it
scrub
a pt with diabetic foot ulcer must have all __ taken off the area
pressure
antiseptic solutions can damage ____ tissue
granulating
not for use in cleaning wounds
liquid or foam pH balanced cleansers
2 kinds of drains attached to collection devices
jackson-pratt and hemovac
3 kinds of mechanical debridement
lavage (irrigation)
wet-to-dry
hydrotherapy (whirlpool)
mechanical debridement that basically like putting tape on the skin and ripping it off
wet to dry
moisture-retaining dressing and the body’s own enzymes to break down necrotic tissue
autolysis
autolysis is contraindicated in the presence of
infection or immunosuppression
a secondary wound dressing it to
hold the primary dressing in place
foam tape is ideal for dressing on
joints
if a dressing requires frequent changes you can use ___ straps
montgomery straps
wafers, pastes, or powders that contain water-loving particles
hydrocolloids
a good dressing for a dry wound
hydrocolloids
enzymatic debridement uses proteolytic agents to break down necrotic tissue without
affecting normal tissue
Braden Score: 6-23. the __ the score more at risk.
lower
Braden Score includes
sensory perception mobility activity moisture nutrition friction and shear
Each item on the braden score is ranked from __ to __
1 to 4
Diabetic ulcers have ___ wound margins
regular
Diabetic ulcers have __ around the wound
callus
Diabetic ulcers, skin characteristics
dry, warm, decreased sensation, charcot
which type of wound closure? closing superficial low-tension wounds such as skin tear and lacerations
adhesive strip
increases the inflammatory phase of wound healing and increases rate of collagen formation: ___ __ growth factor
platelet derived growth factor
rupture of one or more layers of a wound is called
dehiscence
a total separation of the layers of a wound with internal viscera exposed
evisceration
Risk Factors
Older age
Previous history of venous disease or thrombophlebitis
Female
Pregnancy
Obesity
Occupation that involves standing for a long period
Venous ulcers
ulcer that’s usually between the knee and ankle
Venous ulcers
Associated Skin Characteristics Hyperpigmentation of lower calf and ankle skin from hemosiderin staining Firm/hardened skin Dry scaly skin; may be itchy Edema
Venous ulcers
Associated Wound Characteristics
Often shallow
Irregular margins
Drainage
Venous ulcers
ulcer Location
Toes, foot, malleolus
Arterial ulcers
Associated Skin Characteristics
Cool skin temperature
Thin, shiny skin
Decreased or absent skin hair
Painful
Pain may increase when the leg is elevated
Pain may decrease or be relieved when the leg is in a dependent position
Arterial ulcers
Associated Wound Characteristics
Minimal exudate
Pale wound bed; necrotic tissue may cover the wound
Well defined wound margins
Arterial ulcers
