defined the role Flashcards
1
Q
defined the role of nurse
reduced infection rate in military hospitals during Crimean
A
Florence Nightingale
2
Q
factors that influence skin breakdown
A
age, mobility, nutrition, hydration, diminished sensation, impaired circulation, medications, moisture on skin, fever, lifestyle
3
Q
another name for liver spots (age spots)
A
solar lentigo
4
Q
variations of aging
A
decreased sweat/oil glands
senile lentigines
skin tags
decreased hair and nail growth
decreased skin elasticity (wrinkles, sagging, turgor)
hair grays due to reduction in melanocytes
nails thicken, yellow and peel
5
Q
healthy person moves/changes position when experiencing pressure or discomfort
A
mobility
6
Q
protein needed to maintain skin, repairs min defects, edema decreases elasticity
A
nutrition and hydration
7
Q
leads to loss of feeling pressure, heat and cold
A
diminished tactile sensation
8
Q
to low cholesterol can impair
A
wound healing
9
Q
decreased oxygenation/decreased venous and arterial flow
A
impaired circulation
10
Q
NSAID’s and steroids, ibuprofen (more easily to bruising),
coumadin
A
inhibit would healing
11
Q
exposure to maceration (softening of skin), incontinence and fever( most common in bed ridden patients), bowel incontinence
A
moisture on skin causing skin breakdown
12
Q
temperature >101
leads to sweating
sign of infection
triggers immune response which uses calories and nutrients
A
fever
13
Q
multiple daily baths lead to
A
poor skin turgor
14
Q
body’s largest organ
primary defense against infection
A
skin
15
Q
disruption in the integrity of body tissue
A
wound
16
Q
intentional (surgery)/unintentional (getting stabbed) open/closed partial/full thickness (how deep) acute/chronic pressure ulcer stages : 1-4 R-Y-B: red, yellow, black types of wounds
A
classification of wounds
17
Q
slowing healing
had more than two months
A
chronic wound
18
Q
primary intention secondary intention tertiary intention (delayed primary)
A
types of wound healing
19
Q
wound with little tissue loss
edges are approximated
heals rapidly with minimal scarring
healing occurs in 4 stages
A
primary intention
20
Q
wound with loss of tissue edges widely separated healing occurs by granulation large scar increased potential for infection healing time longer heals form the bottom up
A
secondary intention
21
Q
also called delayed primary healing
widely separated wound is later brought together with some type of closure material (may need skin graft)
usually fairly deep
lots of draining
A
tertiary intention
22
Q
vascular response/inflammation
proliferation/regeneration
maturation/remolding
A
physiology of wound healing
23
Q
hemostasis and inflammation being in minutes and last 3- 6 days
blood vessels constricts, blood clots
vasodilation bring nutrients and WBC’s
blood flow reestablished after epithelial cells began to grow
phagocytosis
slight fever
A
vascular response/inflammation
24
Q
day 3 or 4 to day 21
macrophages clear are of debris
begins with appearance of new blood vessels
fills wound with connective or granulation tissue
top is closed by epithelialization
fibroblasts synthesize collagen closes wound
scar is pink and raised
A
proliferation/regeneration
25
layer of pink, pebbly, tissue
| layer gets thicker, becomes beefy read
granulation tissue
26
grows from edges and cover over the granulation (new skin or scar)
is never as strong as original skin
epithelialization (epithelia tissue)
27
starts 3rd week/day 21 and can go long periods
collagen scar gains strength
scar remodels, resumes normal appearance
take months/years to complete
maturation/remodeling
28
serous
sanguinous
serosanguinous
purulent
drainage/exudate
29
clear, watery plasma
serous
30
fresh bleeding
sanguinous
31
pale more watery, combination of plasma
serosanguinous
32
forming pus
thick yellow, green, brown
indicates presence of dead or living organism and white blood cells
purulent
33
```
infection
hemorrhage
dehiscence
evisceration
fistulas
```
complication of healing
34
wound opens partially, can happen when sutures/staples are removed
dehiscence
35
medical emergency
wound keeps going through
mostly seen in stomach and gut will protrude out
cover with sterile 4x4 gauge or sterile towel, do not pack
call doctor
evisceration
36
prevention of tissue dehydration and cell death
accelerated angiogenesis
increased breakdown of tissue and fibrin
reduced pain
keeping moist wound beds
37
normal saline only solution for wound care
| recommended by Agency of Health care
prevent injury to healing tissue
38
```
normal saline: best isotonic
hydrogen-peroxide: delays healing
Dakin's solution: delays healing (bleach solution)
Acetic acid slows healing (vinegar)
commercial products
betadine (povidine-iodine)
```
topical agents used in wounds
39
a major no-no to use in wounds
| removes moisture from wound bed
betadine
40
keep wound bed moist and surrounding skin dry
protect periwound skin
41
```
electrical stimulation and ultrasound
hyperbaric oxygen
negative pressure wound treatment
heat and cold
debridement
dressings
```
wound care treatment
42
intermittent current to wound bed
stimulates granulation
inhibits bacterial growth
limited clinical use
electrical stimulation
43
oxygen delivered at increased atmospheric pressure
improves blood capacity to carry O2 to increase tissure oxygenation
ask patient is they are Claust phobic
hyperbaric oxygen
44
sponge inside wound covered with dressing and connected to negative pressure machine
low suction
works well on wound with excessive drainage
can't use on dry wounds, needs to have exaudates
negative pressure wound treatment
45
acute wounds in inflammatory phase
cold therapy
46
chronic wounds
better for backs
contradicted in arterial insufficiency
heat therapy
47
if deficiency in feet or legs
| could get vasoconstriction
alternate heat and cold
48
very young, older adults with thin skin
open wounds/broken skin where subcutaneous tissue is sensitive
areas of edema or scar information where there is reduced sensation
peripheral vascular disease such as diabetes where body extremities are less sensitive
confusion where there is reduced perception of sensory
spinal cord injury
conditions that increase risk for injury form heat and cold application
49
```
improve blood flow to injured body part
promote delivery of nutrients
removal of wastes
improve delivery of leukocytes to wound site
promote muscle relaxation
reduce pain from spasm or stiffness
increase blood flow
provide local warmth
promote movement of waste products
```
heat therapy
50
```
reduce blood flow to injured site
preventing edema
reduce inflammation
reduce localized pain
reduce oxygen needs of tissues
promote blood coagulation at injury site
```
cold therapy
51
support cut muscles
snug but not restrictive
several types: straight abdominal and Montgomery straps
an example could be an arm sling
binders
52
for abdominal wounds that have to change daily or often
Montgomery straps
53
mechanical, enzymatic, autolytic, sharp
debridement (clean up a wound)
54
scrub, rub, wet/dry damp dressing, irrigation, whirlpool, maggots
mechanical
55
topical medication, collagenase ezymes
enzymatic
56
body does it to itself
| dressings that contain moisture make use of the body's enzymes to break down necrotic tissue
autolytic
57
use of scalpel/scissors
| requires special training
sharp
58
localized injury to the skin and/or underlying tissue usually over bone prominence
result of pressure
result of pressure in combination with shear and/or friction
can form in any person in constant maintained postions(standing, lying, sitting)
pressure from shoe/clothing
constant unchanging pressure
primary cause is pressure
pressure ulcer
59
individuals need not be lying down, or bedridden
to develop tissue ulcerations related to pressure
60
90% of hospital stays involving treatment of pressure ulcers were for conditions other than ones for admission
septicemia, pneumonia UTI, CHF, aspiration pneumonia
61
hospitals stays principally for pressure ulcers
paralysis, SCI, stroke, MS
62
coccyx-sacral area, heels, elbows most susceptible
| heals are worse area
pressure wounds
63
when subcutaneous tissue is compressed between a bony prominence and an external surface for a prolonged peiod
pressure ulcer
64
pressure ulcer sites
see page 1072
65
```
prolonged pressure (lying in bed long periods, unrelieved pressure)
shearing force
friction
moisture
nutrition
infection
impaired peripheral circulation
obesity
age
```
contributing factors for pressure ulcers
66
when patients slide in bed
shearing force
67
two surfaces rubbing against each other
heels and elbows most vulnerable
injury is shallow and without necrosis
limited to the epidermis
friction
68
reduces skin's resistance to pressure and shearing
moisture
69
causes atrophy and decreased subcutaneous tissue
less tissue to pad bones
poor nutrition often overlooked if obese
fluid/electrolyte imbalance
anemia: reduced O2 available
cachexia: person is skin and bones, lost of all adipose
poor nutritional status
70
results in diaphoresis and increased skin moisture
fever
71
without decreased circulation, tissue become hypoxic
| decreased sensation leads to loss of feeling of pressure and limited moment
peripheral circulation
72
adipose tissue had poor vascularity
skin breaks down easier
prone to ischemic changes
obesity
73
lean body mass loss
epidermis thins
changes in collagen (skin looses elasticity)
decreased oil production (skin dryness)
pain perception decreased
peripheral circulation and oxygenation compromised
cells regenerate slower, cause delayed healing
age
74
classified in stages based on depth of tissue destroyed
| four stages
pressure ulcer wounds
75
nonblanchable erythema of the intact skin when you push on it
only the epidermis is involved
reversible if pressure romoved
stage 1 pressure ulcer
76
partial thickness skin loss involving epidermis and/or dermis
skin tears
superficial
presents as an abrasion, blister or shallow crater
may be swollen and painful
more painful that stage IV
wounds are usually open
stage 2 pressure ulcer
77
full thickness skin loss with damage or necrosis of subcutaneous tissue that may extend to but not through, the underlying fascia
presents as deep crater with/without undermining
may have foul-smelling drainage
wound not into muscle
stage 3 pressure ulcer
78
full thickness skin loss with extensive destruction
tissue necrosis or damage to muscle, bone or supporting structures
undermining/tunneling may be present
tendon will be exposed
stage 4 pressure ulcer
79
localized area of purple/maroon discoloration
| red and puffy
suspected deep tissue injury
80
can't see bottom of wound bed
can't tell what stage it is
base of ulcer is covered by slough and/or eschar
unstageable
81
cannot be graded/staged
| depth of wound and tissue type cannont be visualized
necrotic ulcer
82
when scab apprears
is not appropriate designation
physiology impossible for full thickness wounds such as stage 3 and 4 to regenerate
reverse staging
83
1. relieve pressure: frequent turning, pressure relieving, keep wound clean and dry
2. moist healing environment: saline or occlusive dressing
3. debride with wet to dry
4. non-adherant dressing, skin grafts
stage related treatments
84
risk assessment
skin care and early treatment
mechanical loading and support surfaces
education
pressure ulcer prevention
85
consider all who are bed/chair bound or whose ability to reposition themselves is impaired
use Braden, PUSH, Norton
assess regularly: admission and regular intervals
identify: individual risk factors
implement specific preventions modalities
risk assessment
86
the higher the number the better the
22 is the maximum number to get
assesses pressure ulcers
sensory, moisture, activity, mobility, nutrition, friction, shear
Braden scale
87
predictive instruments are used for at-risk patients for
increased early detection
88
```
physical condition
mental condition
activity
mobility
continence
```
Norton Scale
89
enter through direct contact, inhalation, ingestion, insect/animal bite
pathogens
90
primary and secondary
defenses against infection
91
```
skin and normal flora
mucous membranes
sneeze, cough, tearing reflexes
elimination and acidic environments
circulatory system
```
primary defenses
92
first line of defense
skin
93
physical barrier
inhibits growth
traps infection
mucous membranes
94
trap and propel mucous from lung
cilia
95
physical expulsion
sneeze/cough
96
flushing mechanism
tears
97
acidic urine: inhibits growth, cleanse bladder neck
elimination
98
essential to inflammatory and immune response
blood carries components of immunity
removes waste products for tissue
circulatory system
99
increase WBC (lymphocytes) destroy/react to cells the body decides are harmful
inflammatory response stage 1
100
white blood cells
second line of defense
ingest and destroy microbes
normal range < 10,000
leukocytes
101
increased blood flow to the inflamed area
| produces the characteristic signs of redness and increased warmth
stage 2 inflammatory response
102
increased capillary permeability with leakage of large quantities of plasma
infection is walled off
non-pitting edema occurs
stage 3 inflammatory response
103
damaged tissue invaded by leukocytes that engulf bacteria and necrotic tissue
produces purulent
stage 4 inflammatory response
104
destroyed tissue cells replaced by similar cells
promotes tissue healing or formation of scar
functional capacity of tissue may be reduced
stage 5 inflammatory response
105
redness: blood accumulation in dilated capillaries
warmth: heat of the blood
swelling: fluid accumulation
pain: pressure or injury to local nerves
signs and symptoms of inflammation
106
does not equal infection
| is a normal response
inflammation
107
when the body's defenses are overwhelmed
infection
108
surgical wounds
urinary tract
respiratory tract
common sites of infections
109
major cause of hospital morbidity
accounts for 60% extra hospital days
pathogens enter wound at time of surgery
infection rates double for each hour patient is in surgery
surgical wounds
110
most common nosocomial infection
medicare will not for this hospital problem
catheters major causative agents
by-pass cleansing of bladder neck by urine
poor technique
long-term use
improper/poor perineal care
urinary tract
111
second most common site and associated with most deaths
aspiration most common mechanism
stasis of respiratory secretions cause by immobility
decreased cough
respiratory tract
