........ extra Flashcards
stages of inflamatory response
rapid vasoladation of the area
acumilation of fluid at site of injury
formation of exudate at site of injury
formation of granulation tissue
signs of pressure injury in a black people
color remain unchanged when area is pressure is applied
the circumscribed area may warmer or cooler than the surrounding area
skin may differ in firmness either softer or harder
what would measure protein deficiency
serum albunim
serum prealbunim
nitrogen balance
which nutriotion play a big role in wound healing
zinc
copper
vitamin c
avoid ____ _____ ____ when cleaning wound because it may delay wound healing
povidone iodine
hydrogen peroxide
cold irrigation solutions
when assessing a wound what should you look for
wound characteristics
outflow of pus
location of wound
if a patient come to emergince room withopen wound and evisecerated liver what should you do
assess patient for symptoms of shock
contact surgical team
place sterile towels soaked in saline over the wound
wet dressings are a form of
mechanical debridement
when should you avoid wet dressings
with a clean granulating wound
what do wet dressings do
it removes viable as well as devitalized tissue
when caring for a wound a UAP can
observation of changes in skin integrity
changes in dietary intake
measument of the body temp
which vitamins would help paitent wound healing
A
C
shear injury include
underlying muscle and tissue
what are indications of dehisence
popping sensation
increased drainage
stage 1 pressure injury charisteristic
localized non blanchable erythema
warm edematous skin
cooler than the adjacent tissue
before applying heat therapies the nurse should assess the patient for the presence of which potential contrainications
neuropathies
local abscess
open wound
cardiovascular status
if there is a bacterial count of 10^5 per gram of tissue what should you expect
tissue destruction at the site of wound
a delay in colagen synthesis in the wound
thick purulent drainage at the site of wound
what is the body fluid with the lowest risk for skin breakdown?
salvia
patient has a diabetic ulcer doctor ordered vac therapy for which condition would the nurse assess to prevent therapy complications
fistula
osteomyelitis
what are the benefits of bandaging a patient leg wound
promotes venous return
increases hemostatic pressure
decrease blood pooling in the lower extermities
the 3 type of people with risk of wound dehiscence
malnourished patient
obese patient
patient with wound infection
the three c’s of nutrition
vitamin c
zinc
copper
what another word for pus
purulent
raising the leg of patient prevents
venous return
serosanguineous drainage looks
pink to pale red fluid
neutrophils and macrophages do what to the wound
clean
braden scale measures
sensory
moisture
activity
mobility
nutrition
friction and shear
braden scale sensory
1- completly limited
2-very limited
3- slightly limited
4-no impairment
braden scale moisture
1- constantly moist
2- very moist
3- occasionally moist
4- rarely moist
braden scale activity
1-bedfast
2-chairfast
3- walks occasionally
4walks frequently
braden scale mobility
1- completely immobile
2- very limited
3-slightly limited
4- no limitation
braden scale nurtriton
1- very poor
2-probably inadequate
3-adequate
4-excelent
braden scale friction and shear
1- problem
2-potential problem
3- no apparent problem
Norton scale measure
physical condition
mental state
activity
mobility
contience
Norton scale physical condition
4 -good
3-fair
2-poor
1-bad
Norton scale mental state
4-alert
3-apathetic
2-confused
1-stupor
Norton scale activity
4- fully mobile
3- slightly limited
2-very limited
1-immoble
Norton scale contience
4- continent
3- occasional incontenece
2- usual incontinent of urine
1- incontinent of bowel and bladder
The PSST assigns a numerical score based on
13 wound attributes
the PUSH tool’s score is based on
three characteristics
the PUSH tool’s score is based on
wound size, tissue type, and exudate amount
