Fundamentals Exam 2 Flashcards
Slough
Liquified or wet dead tissue. White, yellow, light tan
Eschar
Dried dead tissue, cornified, tan brown, black
Undermining
Bigger wound than opening. Extends under the edge
Tunneling
Tracts extend out from the wound
Exudate
Drainage of pus, yellow fluid
Stage 1
Intact skin, no blanching red area usually over bony prominence
Stage 2
Shallow open ulcer with redor pink wound bed w/o slough. Partial thickness, shiny, dry, shallow ulcer. No slough or bruising.
Stage 3
SubQ fat may be seen. Slough, no exposed bone, muscle, or tendon. May have undermining or tunneling
Stage 4
Exposed bone , tendon, or muscle. May have slough, eschar, undermining or tunneling
Unstageable
Full thickness, base or wound bed covered by slough or eschar. Often includes tunneling and/or undermining
Deep tissue injury
Purple/maroon localized area of discolored skin
Moisture wound
Partial thickness, shallow craters, linear denuded skin in creases. From moisture
Wound Measurement orientation
Like clock
Length 12-6
Width 3-9
Depth- deepest from wound edge to bottom. Unable if eschar or slough
Serous Drainage
Clear fluid like in blister
Sanguineous drainage
Contains RBC’s
Serosanguineous
Combo clear with blood tint
Purulent
Contains wbc’s
Heat therapy
Dilates peripheral blood vessels
muscle tension
>pain
Cold therapy
Constricts peripheral blood vessels
>muscle spasm
Promotes numbness
Promotes comfort
HIPAA
1996 Health Insurance Portability Accountability Act
SBAR
Situation-concise statement of problem
Background-brief, pertinent info.
Assessment-what found/thought
Recommendation-action requested
Acute pain
Rapid onset
Chronic pain
Longer can have breaks and exacerbations
Cutaneous pain
Superficial pain close to surface
Somatic pain
Originates in tendon, bone , muscle, ligament, blood vessel, nerves
Visceral pain
Poorly localized. Originates in thorax, cranium, abdomen
Mode of transmission- pain
Referred pain
Pain perceived in different site than origination
Neuropathic pain
Damage/abnormal fxn of peripheral nerves or CNS
Intractable pain
Therapy resistant despite multiple intervention
Phantom pain
Pain experienced in lost limb/body part
FLACC pain scale
Faces Legs Activity Cry Consolability
Numerical sedation scale
1=awake/alert
2=drowsy occasionally, but easily aroused.
3=drowsy frequently, falls asleep in conversation. Reduce Dose
4=somnolent, minimal response. Discontinue opioid try naloxone
% of brain is water
75
% of blood is water
83
%of muscles is water
75
Extracellular
Outside cells
Interstitial
Between cells and outside blood vessels
Intravascular
Blood plasma
Transcellular
Cerebrospinal, pleural, peritoneal, and synovial
Intracellular
Within cells
Desired adult fluid intakes n 24 hr
1500-3500 ml in 24hr
Amt. Most adults average of water
2500-2600ml/day
Sensible losses
Are fluid losses from urination, defecation, and wound. these can be measured
Insensible losses
Are losses via skin and lungs about 28%
Sodium
Regulates extra cellular fluid
135-145 mEq/L
Potassium
Plays a vital role in electrical impulses
3.5-5.0 mEq/L
Calcium
Plays major role in transmission of nerve impulses
9.0-10.5 mg/dL
Magnesium
Acts on cardiovascular system
1.2-2.0 mEq/L
Chloride
Major component of interstitial and lymph fluid
97-107 mEq/L
Hyponatremia
Na+ <135mEq/L
Symp: tachycardia, hypotension, mu. cramps, weakness, lethargy,HA
Causes=GI losses, diuretics, excess h20 intake, burns, kidney disease.
Tx based on cause
Hypernatremia
Na+ >145mEq/L
Symp: irritable, thirst, fever, dry &. Flushed skin, dry tongue & mucus membrane, muscle twitch
Causes=<intake Na+
Tx based o cause
Potassium
Fx= cardiac, skeletal, & smooth muscle fx.
Maintains fluid volume w/I cell
Metabolism of CHO & Pro-
Hypokalemia
muscle tone, paresthesias
Causes=diuretics, GI losses, Diaphoresis,
Tx= K+ replacement
Hyperkalemia
> 5.0mEq/L
Symp: cardiac arrhythmia, hypotension, anxiety, muscle weak
Causes=renal failure, diabetic ketoacidosis.
Tx=Kayexelate
Calcium
Most abundant mineral Development of teeth & bones Req. for transmission of nerve impulses Skeletal and cardiac muscle contraction Regulates heart beat & BP Vit D required for absorption
Hypocalcemia
<9.0mg/dL
Symptoms: numbness, tingling in fingers and toes, muscle twitch, seizures, laryngeal spasm.
Causes=Vit D deficiency, pancreatitis .
Tx= Ca2+ supplement w/VitD
Hypercalcemia
> 10.5mg/dL
Symp: lethargy, muscle weak, kidney stones, > memory
Causes=hyperparathyroidism, excess Vit D intake,
Tx = identify underlying cause
Magnesium
Fx= activates co-factor in over 300 enzymes. Affects neuromuscular irritability & contractions, contributes to cardiovascular regulation, stabilizes excitable membranes Ca2+
Total water volume in body
50-60% intracellular has 70% of total body water
Water content variations
Age, body fat, gender
Infants have more total body fluid. More prone to deficit
Hypomagnesemia
<reflexes and muscle tremor, tachycardia, confusion
Causes-malnutrition, alcoholism, D, NG suction
Tx give Magnesium
Hypermagnesemia
> 2.0mEq/dL
HTN, flushing, skin warmth, >R
Causes=renal failure
Tx symptomatic
Hypovolemia/hypervolemia
H2O and electrolyte loss/retention
Body systems that have a role in fluid/electrolyte homeostasis
Kidney, CVSystem, adrenal glands, pituitary gland, nervous system, thyroid/parathyroid gland, GI, hypothalamus.
Fluid balance is threatened with any organ/system failure
Acidosis
PH below 7.35
Death at 6.80-
Alkalosis
PH above 7.45
Death at 7.80+
Homeostatic PH regulators
•chemical buffer system
**•respiratory mechanism
•renal mechanism
Effectiveness varies with development infant & AA less eff.
