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aa orgo > 301 Test 2 part 3 > Flashcards

301 Test 2 part 3 Flashcards

1
Q

a small red or purple spot caused by bleeding into the skin.

A

Petechaie

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2
Q

(Melanoma) ___ cell carcinoma-most common doesn’t usually spread (sun)

A

Basal

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3
Q

___ cell carcinoma- more serious than basal. Travel to lymph odes and thoughout the body(sun)

A

Squamous

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4
Q

Moisture: diaphoresis occurs w ___ or decrease in __ __

A

thyrotoxicosis
or
decrease in tissue perfusion

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5
Q

very thin, shiny skin (atrophic) occurs w __ insufficiency

A

arterial

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6
Q

Edema: most evident in dependent areas, feet, ___, sacral areas

A

ankles

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7
Q

blotches in the skin that Jen had

A

vitiligo

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8
Q

circular lesions that begin in the center and spread to the periphery (i.e. ringworm, tinea)

A

Annular

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9
Q

lesions that run together

A

Confluent

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10
Q

distinct, individual lesions that remain separate

A

Discrete

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11
Q

cluster of lesions (i.e. vesicles of contact dermitis)

A

Grouped

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12
Q

lesions take form of a scratch, streak, line or stripe

A

Linear

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13
Q

lesions tatke a linerar arrangement along a nerve route (herpes zoster-shingles)

A

Zosteriform

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14
Q

besides destruction of skin, a defining characteristic of impaired skin integrity is

A

Invasion of body structures

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15
Q

Pressure compresses underlying tissue, hindering ___ flow and nutrient supply

A

blood

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16
Q

high risk areas for pressure ulcers (mostly bony prominences)

A

sacrum, trochanter, ears, heels, knees, iliac crest, shoulder, scapula

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17
Q

a narrow channel of tissue loss that can extend in any direction away from the wound through soft tissue and muscle.

A

tunnel

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18
Q

may result in dead space which can complicate wound healing.

A

tunnel

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19
Q

refers to tissue destruction underneath intact skin at the wound edge.

A

Undermining

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20
Q

Wound edges are not attached to the wound

A

base. Rather, skin edges overhang the periphery of the wound.

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21
Q

necrotic tissue. Usually yellow or tan and slimy

A

Slough

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22
Q

DTI (deep tissue injury) is most common on

A

sacrum, coccyx, and heels

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23
Q

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.

A

Unstagable

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24
Q

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.

A

Stage I

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25
Q

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.

A

Stage 2

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26
Q

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

A

Stage 3

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27
Q

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. These ulcers often include undermining and tunneling

A

Stage 4

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28
Q

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.

A

Suspected deep tissue injury

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29
Q

oder of Wound healing

A

Inflammation
Proliferation
Maturation

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30
Q

which phase (inflammation, Proliferation, Maturation), hemostasis is established

A

inflammation

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31
Q

which phase (inflammation, Proliferation, Maturation), Bacteria, devitalized tissue and other debris are ingested by phagocytes and removed

A

inflammation

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32
Q

which phase (inflammation, Proliferation, Maturation), new tissue forms (granulation and epithelialization) and the wound contracts

A

Proliferation

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33
Q

which phase (inflammation, Proliferation, Maturation), scar tissue is remodeled and strengthened

A

Maturation

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34
Q

Formation of collagen and capillaries in full thickness wounds from surrounding connective tissue. Appears as beefy red tissue in the wound bed

A

Granulation

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35
Q

Appears clinically as tissue that is thin, pearly or silvery and shiny

A

Epithelialization

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36
Q

Seen clinically as a reduction in wound depth and size

A

Wound contraction

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37
Q

in wound healing, The maturation phase may last for one __ or longer.

A

year

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38
Q

a rash of purple spots on the skin caused by internal bleeding from small blood vessels

A

purpura

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39
Q

a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.

A

ecchymosis

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40
Q

Thin, shiny skin, Decreased or absent skin hair, and pain are associated with

A

arterial ulcer

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41
Q

Associated Wound Characteristics
Minimal exudate
Pale wound bed; necrotic tissue may cover the wound
Well defined wound margins

A

arterial ulcer

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42
Q

Risk Factors
Older age
Previous history of venous disease or thrombophlebitis
Female
Pregnancy
Obesity
Occupation that involves standing for a long period

A

Venous ulcers

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43
Q

Venous ulcers location

A

Between the knee and the ankle

Usually between the lower calf and ankle in the area covered by a sock

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44
Q 
Associated Skin Characteristics 
Hyperpigmentation of lower calf and ankle skin from hemosiderin staining 
Firm/hardened skin 
Dry scaly skin; may be itchy 
Edema
A

Venous ulcers

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45
Q

Associated Wound Characteristics
Often shallow
Irregular margins
Drainage

A

Venous ulcers

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46
Q

Treatment

Compression therapy often with multi layer wraps to reduce edema (una boot)

A

Venous ulcers

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47
Q

Treatment
Dressings such as alginates and foams to absorb drainage and exudates
Avoid moisture

A

Venous ulcers

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48
Q

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

A

Diabetic ulcers

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49
Q

Wound Location

Usually on metatarsal head, top of toes, and foot

A

Diabetic ulcers

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50
Q 
Associated Skin Characteristics
Dry, cracked skin
Warm skin 
Decreased sensation (neuropathy)
Charcot's foot
A

Diabetic ulcers

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51
Q

Associated Wound Characteristics
Regular wound margins
Callus around wound

A

Diabetic ulcers

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52
Q

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

A

30 and 1.25

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53
Q

Pressure ulcer management, transparent dressing (maybe)

A

1

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54
Q

Pressure ulcer management, Don’t massage. Turning, hydration, nutrition

A

1

55
Q

Pressure ulcer management, If clean: hydrogel to provide moist environment w hydrocolloid dressing (3-7 days)

A

2

56
Q

Pressure ulcer management, If clean: hydrogel, foam dressing, alginate dressing for excessive drainage, gauze

A

3

57
Q

Pressure ulcer management, If clean: hydrogel, alginate for drainage, gauze, growth factors

A

4

58
Q

Pressure ulcer management, if stable leave and maintain

If not stable, may use enzymatic ointment, or debridment may be needed

A

Eschar

59
Q

Pressure ulcer management, Debridment, enzymatic ointment, cover w hydrocolloid for autolytic debridment

A

Necrotic

60
Q

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

A

Cheyne-Stokes respiration

61
Q

an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.

A

Biot’s respiration

62
Q

he abnormal transmission of sounds from the lungs or bronchi

A

Bronchophony

63
Q

an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis.

A

Egophony

64
Q

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).

A

Whispered pectoriloquy

65
Q

Forced expiratory time
Pulse oximeter
6-Minute distance walk

A

Measurement of pulmonary function status

66
Q

a condition in which a person’s breastbone is sunken into his or her chest

A

Pectus excavatum

67
Q

a breastbone (sternum) and rib cartilage deformity that causes the chest to bow outward

A

Pectus carinatum

68
Q

resp gradually increase in rate and depth then decrease. Lasts vron 30-45 seconds w periods of apnea.

A

Cheyne-Stokes respiration

69
Q

Occurs normally in infants and aging persons during sleep. May see w chg, renal failure, meningitis, drug overdose, increased intracranial pressure.

A

Cheyne-Stokes respiration

70
Q

similar to cheyne stokes except pattern is irregular. Seen w head trauma, brain abscess, heatstroke, spinal meningitis and encephalistis

A

Biots

71
Q

a palpable vibration produced during breathing caused by partial airway obstruction. The obstruction can be due to mucus or other secretions in the airway

A

Rhonchial fremitus

72
Q

palpable vibration of the wall of the thorax caused by friction between the parietal and visceral pleura of the lungs

A

Pleural friction fremitus

73
Q

percussing the lungs, hyper resonance means too much

A

air (emphysema or pneumothorax)

74
Q

percussing the lungs, dull sound means the density is too

A

high (pneumonia, atelectasis, tumor)

75
Q

tympany is aka

A

hyper resonance

76
Q

Best time for BSE is after the

A

menstrual period

77
Q

Amount of blood ejected from the left ventricle each minute

A

Cardiac Output

78
Q

End diastolic pressure

A

Preload

79
Q

Resistance to left ventricular ejection

A

Afterload

80
Q

Amount of blood ejected from the left ventricle with each contraction

A

Stroke Volume

81
Q

the amount of air exhaled in a normal breath

A

Tidal volume

82
Q

Hypovolemia

Increased metabolic rate

A

Factors Affecting Oxygenation

83
Q 
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
A

S&S of IGE

84
Q 
Barrel chest
Clubbng 
Polycedthemia vera
Increased RR
Cough 
Wheezing 
Changes in ABG
blue bloater and pink puffer
A

Chronic gas exchange problems: S&S

85
Q

Dyspnea Management: Humidification is necessary for clients receiving more than _ L/minute of oxygen

A

4

86
Q

Used when the client can cough effectively but is not able to clear secretions

A

Oropharyngeal and nasopharyngeal

87
Q

Used when the client is unable to manage secretions

A

Orotracheal and nasotracheal

88
Q

chronic disorder that can result in enlarged and misshapen bones

A

Paget’s disease of bone (osteitis deformans)

89
Q

an extremely rare syndrome that results when the anterior pituitary gland produces excess growth hormone

A

Acromegaly

90
Q

crutch walking: lead with affected leg when going __ stairs

A

up

91
Q

crutch walking: lead with unaffected leg when going __ stairs

A

down

92
Q

Clean wounds are uninfected and have minimal

A

inflammation

93
Q

surgical incisions that enter the GI, respiratory, or GU tract: c__ c__ wounds

A

clean-contaminated wounds

94
Q

___ wounds have a major break in asepsis but are not necessarily infected

A

contaminated

95
Q

type of wound that extends through the epidermis but not through the dermis

A

partially thickness wound

96
Q

type of wound that extends into the sub q and beyond

A

full thickness wound

97
Q

promotes granulation tissue, reduces edema, removes exudate and infectious material

A

negative pressure wound therapy

98
Q

silver dressings are used to control

A

bacteria

99
Q

Electrical stimulation promotes

A

cell growth

100
Q

stimulates growth of blood vessels and assists WBC

A

hyperbaric oxygen therapy

101
Q

wound care that’s indicated for diabetic wounds and other nonhealing wounds free of necrotic tissue

A

tissue growth factors

102
Q

wound care that stimulates movement of fluid of cells and helps with debridement

A

ultrasound

103
Q

If a wound is necrotic dont __ it

A

scrub

104
Q

a pt with diabetic foot ulcer must have all __ taken off the area

A

pressure

105
Q

antiseptic solutions can damage ____ tissue

A

granulating

106
Q

not for use in cleaning wounds

A

liquid or foam pH balanced cleansers

107
Q

2 kinds of drains attached to collection devices

A

jackson-pratt and hemovac

108
Q

3 kinds of mechanical debridement

A

lavage (irrigation)
wet-to-dry
hydrotherapy (whirlpool)

109
Q

mechanical debridement that basically like putting tape on the skin and ripping it off

A

wet to dry

110
Q

moisture-retaining dressing and the body’s own enzymes to break down necrotic tissue

A

autolysis

111
Q

autolysis is contraindicated in the presence of

A

infection or immunosuppression

112
Q

a secondary wound dressing it to

A

hold the primary dressing in place

113
Q

foam tape is ideal for dressing on

A

joints

114
Q

if a dressing requires frequent changes you can use ___ straps

A

montgomery straps

115
Q

wafers, pastes, or powders that contain water-loving particles

A

hydrocolloids

116
Q

a good dressing for a dry wound

A

hydrocolloids

117
Q

enzymatic debridement uses proteolytic agents to break down necrotic tissue without

A

affecting normal tissue

118
Q

Braden Score: 6-23. the __ the score more at risk.

A

lower

119
Q

Braden Score includes

A 
sensory perception
mobility
activity
moisture
nutrition
friction and shear
120
Q

Each item on the braden score is ranked from __ to __

A

1 to 4

121
Q

Diabetic ulcers have ___ wound margins

A

regular

122
Q

Diabetic ulcers have __ around the wound

A

callus

123
Q

Diabetic ulcers, skin characteristics

A

dry, warm, decreased sensation, charcot

124
Q

which type of wound closure? closing superficial low-tension wounds such as skin tear and lacerations

A

adhesive strip

125
Q

increases the inflammatory phase of wound healing and increases rate of collagen formation: ___ __ growth factor

A

platelet derived growth factor

126
Q

rupture of one or more layers of a wound is called

A

dehiscence

127
Q

a total separation of the layers of a wound with internal viscera exposed

A

evisceration

128
Q

Risk Factors
Older age
Previous history of venous disease or thrombophlebitis
Female
Pregnancy
Obesity
Occupation that involves standing for a long period

A

Venous ulcers

129
Q

ulcer that’s usually between the knee and ankle

A

Venous ulcers

130
Q 
Associated Skin Characteristics 
Hyperpigmentation of lower calf and ankle skin from hemosiderin staining 
Firm/hardened skin 
Dry scaly skin; may be itchy 
Edema
A

Venous ulcers

131
Q

Associated Wound Characteristics
Often shallow
Irregular margins
Drainage

A

Venous ulcers

132
Q

ulcer Location

Toes, foot, malleolus

A

Arterial ulcers

133
Q

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

A

Arterial ulcers

134
Q

Associated Wound Characteristics
Minimal exudate
Pale wound bed; necrotic tissue may cover the wound
Well defined wound margins

A

Arterial ulcers

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