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NRSG 102: Med Surg 1 > Exam 4: Chapter 30: Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation > Flashcards

Exam 4: Chapter 30: Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation Flashcards

1
Q

What is a leg ulcer?

A

An excavation of the skin surface that occurs when inflamed necrotic tissue sloughs off.

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2
Q

Patho behind leg ulcers?/

A

Inadequate exchange of oxygen and other nutrients in the tissue is the metabolic abnormality that underlies this development

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3
Q

Alternations in blood vessels at the arterial, capillary, and venous levels may affect

A

cellular processes and lead to the formation of ulcers

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4
Q

Chronic arterial disease is characterized by

A

intermittent claudication, which is pain caused by activity and relieved after a few minutes of rest

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5
Q

Patients with Arterial Ulclers may also complain of

A

digital or forefoot pain at rest

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6
Q

If arterial occlusion is acute, pain is

A

unrelenting and rarely relieved even with opoids

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7
Q

Typically, arterial ulcers are

A

small, circular, deep ulcerations on the tips of toes or in the web spaces between the toes

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8
Q

Ulcers often occur on the

A

medial side of the halllux, or lateral fifth toe and may be caused by a combination of ischemia and pressure

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9
Q

Arterial Ulcers and Edema and Pulses?

A

No Edema / No Pulse or Weak Pulse

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10
Q

Chronic Venous Insufficiency is characterized by

A

pain described as aching or heavy.

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11
Q

Venous Ulcers are in the area of

A

the medial or lateral malleolus and are typically large, superfiical, or lateral malleolus and are typically large, superfifical, and highly exudative

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12
Q

Venous Ulcers: Venous Hypertension causes

A

extravasation of blood, which discolors the area.

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13
Q

Arterial ulcer occurs where?

A

A clot at the very end of the foot

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14
Q

A ulcer from venous stasis happens around the

A

ankle

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15
Q

What Antiseptic Agents can inhibit the growth and development of most skin organisms?

A

Povidone-Iodine

Cadexomer Iodine

Acetic Acid

Chlorhexidine

Silver Wound Products

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16
Q

Once a wound is colonized with pathogens shows signs of infection, a

A

systemic antibiotic is necessary

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17
Q

What antibiotic is suaully prescribed for leg ulcers?

A

Oral Antibiotics usually are prescribed because topical antibiotics have not proven to be effective

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18
Q

Nutrition and Leg Ulcers

A

They need protein, and this can be tested by Albumin

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19
Q

Why does Compression Therapy work for Leg Ulcers?

A

Adequate compression therapy involves the application of external or counter pressure to the lower extremity to facilitate venous return to the heart

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20
Q

How long should the patient wear stockings for?

A

At all times except at night and to reapply the stockings in the mornin g

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21
Q

Debridement: To promote healing the wound is

A

kept clean of drainage and necrotic tissue

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22
Q

Debridement: Usual method is to

A

flush teh area with normal saline solution or clean it with a noncytotoxic wound-cleansing agent

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23
Q

Debridement: What is this?

A

Removal of nonviable tissue from wounds. Can be accomplished by several different methods.

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24
Q

What is Surgical Debridement:

A

Fastest method and can be performed by a physician or other qualified person

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25
Q

What is Nonselective Debridement:

A

Can be accomplished by applying isotonic saline dressing of fine mesh gauze to the ulcer. When dressing dries, it is removed along with debris adhereing to gauze

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26
Q

What is Enzymatic Debridement:

A

Application of enzyme ointments may be prescribed to reat the ulcer. Ointment applied to lesion.

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27
Q

What are Calcium Alginate Dressings useful for?

A

Used for debridemenet when absorption of exudate is neded. Dressings changed when exudate seeps through the cover dressing or at least every 7 days

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28
Q

Why are foam dressings useful?

A

They absorb exudate into the foam, keeping the wound moist

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29
Q

Wound Dressing: SEmiocclusive or Occlusive Wound Dressings prevent

A

evaporative water loss from the wound and retain warmth; these factors facor healing

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30
Q

Wound Dressing: Available options that promote the growth of granulation tissue and reepithelization include

A

the hydrocolloids

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31
Q

Hydrocolloids also provide a

A

barrier for protection because they adhere to the wound bed and surrounding tissue.

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32
Q

Wound Dressing: Foam Dressings are permeable to both

A

gases and water vapor due to their hydrophilic properties and are indicated for wounds with moderate exudate, granulating, or slough covered

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33
Q

Wound Dressing: Semipermeable film dressings may be selected because

A

they keep the wound moist and are impervious to bacteria while allowing some gas exchange. May not be effective treatment for deep wounds and infected wounds

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34
Q

Wound Dressing: GRowth Factor dressings may directly provide

A

a growth factor, or they may stimulate important growth substances within the wound

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35
Q

Wound Dressing: Calcium Alginate, Hydrofiber, and Hydroconductive dresings are used for wounds with

A

moderate to high amounts of exudate

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36
Q

Wound Dressing: Hydroconductive dressings provide

A

a capillary action that lifts and moves exudate away from a wound into the core of the dressing form where is disperses into second layer

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37
Q

Stimulated Healing: Tissue-engineered human skin equivalent is a

A

skin product cultured form human dermal fibroblasts and keratinocytes used in combination with therapeutic compression

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38
Q

Stimulated Healing: When applied, it

A

interacts with the patients cells within the wound to stimulate the production of growth factors

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39
Q

Stimulated Healing: What is PriMatrix

A

A bioactive and regenerative extracellular matrix that binds with the patietns own cells and growth factors

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40
Q

Stimulated Healing: PriMatrix has been used successfully for

A

tunneling wounds, as well as wounds with exposed tendon and bone, in which Apligraf cannot be used.

41
Q

Hyperbaric Oxygenation: May be beneficial as

A

an adjunct treatment in patietns with diabetes with no signs of wound healing after 30 days of standard wound treatment

42
Q

Hyperbaric Oxygenation: Accomplished by

A

placing the apteitn into a chamber that increases barometric pressure while the patient is breathing 100% oxygem

43
Q

Hyperbaric Oxygenation: Treatment regimens vary from

A

90 to 120 minutes once dail for 30 - 90 dessions

44
Q

Hyperbaric Oxygenation: Edema in wound area decreased because

A

high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria.

45
Q

Hyperbaric Oxygenation: Also thought to

A

increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production

46
Q

Hyperbaric Oxygenation: Two most common adverse effects are

A

middle-ear barotrauma and confinement anxiety

47
Q

Negative Pressure Wound Therapy: Research findings suggest that

A

negative pressure wound herapy using vacuum-assisted closure (VAC) devices decreases time to healing in complex wounds that have not healed in a 3-week period

48
Q

Negative Pressure Wound Therapy: Wound VAC therapy has been found to be effective in treating pateints who develop

A

postoperative groind wound infections, decreasing hospital length of stay, rates of graft infection, and likelihood ofl imb loss

49
Q

Nursing Diagnoses for Leg Ulcers

A

Impaired Skin Integrity RT Vascular Insufficiency

Impaired Physical Mobility RT Active Restrictions of the Therapeutic Regimen and Pain

Imbalance Nutrition

50
Q

Potential complications of Leg Ulcers may include

A

Infection

Gengrene

51
Q

Major goals for patient with Leg Ulcers include

A

restoration of skin integrity

Improved physical mobility

Adequate nutrition

Absence of complications

HEAL ULCER

52
Q

Restoring Skin Integrity: Cleansing requires

A

very gentle handling, a mild soap, and lukewarm water

53
Q

Restoring Skin Integrity: If there is arterial insufficiency, patient should be referred for

A

evaluation of vascular reconstruction

54
Q

Restoring Skin Integrity: is there is venous insufficiency,

A

dependent edema cna be avoided by elevating the lower extremities

55
Q

Restoring Skin Integrity: Decrease in edema promotes

A

the exchange of cellular nutrients and waste products in the area of the ulcer, promoting healing

56
Q

Restoring Skin Integrity: Protective boots useful because

A

they are soft and provide warmth and protection from injury and displace tissue pressure to prevent ulcer formation

57
Q

Restoring Skin Integrity: If pt on bed rest, important to

A

relieve pressure on the heels to prevent pressure ulcerations

58
Q

Restoring Skin Integrity: When in bed, what can be used to relieve pressure from bed linens?

A

Bed cradle, and also prevents anything from touching the legs

59
Q

Restoring Skin Integrity: HEating pads, hot water bottles, or hot baths are avoided because

A

they increase the oxygen demands and this the blood flow demands of the already compromised tissue.

60
Q

Restoring Skin Integrity: Heating pads problematic with diabetics because

A

heating pads may produce injury before the patient is aware of being burned

61
Q

Improving Physical Mobility: Physical activity is initally

A

restricted to promote healing

62
Q

Improving Physical Mobility: When infection resolves and healing begins, ambulation should

A

resume gradually and progressively

63
Q

Improving Physical Mobility: activity promotes

A

arterial flow and venous return and is encourage after the acute phase of the ulcer process

64
Q

Improving Physical Mobility: Activity to promote blood flow;

A

encourage patient to move about in bed and exercise upper extremities

65
Q

Improving Physical Mobility: If pain is present

A

Analgesic agents may be taken before scheduled activities to help the patient participate more comfortably

66
Q

Promoting Adequate Nutrition: Eating a diet high in what promotes healing?

A

protein, Vitamins C and A, Iron, and Zinc is encouraged to promote healing.

67
Q

Promoting Adequate Nutrition: Particular consideration should be given to

A

iron intake, because many older patients are at risk for iron deficiency anemia

68
Q

Expected Outcomes

A

Demonstrates Restored Skin integrity

Increased Physical Mobility

Attains Adequate Nutrition

69
Q

What is Cellulitis?

A

Most common infectious cause of limb swelling

70
Q

Cellulitis can occur as

A

single isolated event or a series of recurrent events

71
Q

Cellulitis occurs when

A

an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissues

72
Q

Cellulitis: Pathogen is usually

A

Sreptoccus speices or S. Aureus

73
Q

Cellulitis: Signs and Symptoms include

A

swelling, localized redness, warmth, and pain

74
Q

Cellulitis: systemic signs include

A

fever, chills, and sweating

Regional lymph nodes may also be tender and enlarged

75
Q

Cellulitis: Redness may not be uniform and often skips areas and eventually develops

A

a pitting “orange” peel appearance.

76
Q

Mild cases of Cellulitis can be treated on

A

an outpatient basis with oral antibiotic therapy

77
Q

If Cellulitis is severe, patient is treated with

A

IV antibiotics

78
Q

Key to preventing recurrent episodes of Cellulitis lies in

A

adequate antibiotic therapy for the initial event and in identifying the site of bacterial entry

79
Q

Cellulitis: Cracks and Fisures that occur in the skin between the toes must be

A

examined as potential sites of abcterial entry

80
Q

Cellulitis: Other entry points include

A

Drug Use Injection Sites, Contusions, Abrasions, Ulceration, Ingrown Toenails, Hangnails

81
Q

Cellulitis: Patient is instructed to elevate the affected area to

A

3-6 inches above heart level and apply cool, moist packs at teh site every 2-4 hours until inflammation has resolved and then transition to warm packs

82
Q

Cellulitis: ducation should focus on

A

preventing a recurrent episode. Patient with peripheral vascular disease or diabetes should recieve education or reinforcement about skin and foot care

83
Q

Cellulitis:Labs for this?

A

WBC. Also monitor temperature

84
Q

Stage 1 Pressure Ulcer

A

Sign of Risk. Intact skin with nonblanchable redness of localized area

85
Q

Stage II Pressure Ulcer

A

Partial thickness loss of dermis presenting as shallow open ulcer with red or pink wound bed

86
Q

Stage III Pressure Ulcer

A

Full-thickness tissue loss. Subcutaneous may be visible but bone, tendon, or muscle are not exposed. Slough may be present

87
Q

Stage IV Pressure Ulcer

A

Bone is exposed here

88
Q

If pressure continues long enoug,

A

small vessel thrombosis and tissue necrosis occur and pressure ulcer results

89
Q

Susceptible areas for pressure ulcers include

A

sacrum and coccygeal areas, ischial tuberosities, greater trochanter, heel,, knee, malleolus, medial condyle of the tibia, fibular head, scapula, and elbow

90
Q

Prolonged pressure impedes

A

blood flow, reducing nourishment of the skin and underlying tissues

91
Q

Anemia decreases the

A

bloods oxygen carry ability and predisposes the patient to pressure ulcers.

92
Q

Serum albumin and prealbumin levels are sensitive indicators of

A

protein deficiency

93
Q

Serum albumin levels of less than 3 are associated with

A

hypoalbuminemic tissue edema and increased risk for pressure ulcers

94
Q

Prealbumin levels are more sensitive indicator of

A

protein status than albumin levels

95
Q

Shear is the result of

A

gravity pushing down on the patients body and resistance between the patient and the chair or bed

96
Q

When shear occurs,

A

tissue layers slide over one another, blood vessels stretch and twist, and the microcirculation of the skin and subcutaneous tissue is disrupted

97
Q

Improving Tissue Perfusion: Massage of erythematous areas avoided because

A

damage to the capillaries and deep tissue may occur

98
Q

Improving Tissue Perfusion: In patients who hav evidence of compromised peripheral circulation (edema),

A

positioning and elevation of the edematous body part ot promote venous return and dimish congestion improve tissue perfusion

NRSG 102: Med Surg 1 (52 decks)

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