lab quiz 7 Flashcards
skin changes with age
- Elasticity and collagen are reduced
- Underlying muscles and tissues are thinned
- Comorbid conditions
- polypharmacy
- reduced inflammatory response
pressure injuries
- Form due to pressure intensity (tissue ischemia, blanching), pressure duration, and tissue intolerance
- This leads to economic consequences when ineffectively prevented or treated in healthcare facilities
- Occur over bony prominences
stage 1
non-blanchable erythema of intact skin
stage 2
partial-thickness skin loss with exposed dermis
stage 3
Full-thickness skin loss
stage 4
full-thickness skin and tissue loss
deep tissue
purple or maroon, non-blanching and boggy
unstageable
full-thickness tissue loss and eschar/slough with necrotic tissue
stages of partial-thickness wound repair
- inflammatory
- proliferative
- maturation
stages of full-thickness wound repair
- hemostasis
- inflammatory
- proliferative
- maturation
primary intention
- incision with a blood clot
- sutures
- fine scar
secondary intention
- irregular large wound
- epithelial cells and sutures
- large scar
tertiary intention
- contaminated wound
- increased granulation
- late suturing with large scar
Complications of wound healing
- Hemorrhage: excessive bleeding (internal or external)
- Infection: erythema, purulent drainage
- Dehiscence: reopening of a wound closure
- Evisceration: internal organs are on the outside (cover with sterile gauze)
wound prevention
- Assess patients at risk using the Braden scale
- Intervene when applicable and indicated
wound risk factors
- Impaired sensory perception, perfusion, or mobility
- Altered LOC
- Shear and friction
- Moisture
- Nutrition
- Age or underlying conditions
Risk for breakdown (Braden scale)
- Sensation
- Mobility
- Continence
- Wound presence
- Wound history
- Skin integrity
- medical/assistive devices
assessing wound appearance
- Location and type
- Extent of tissue damage
- Type of tissue in the wound base
- Edge of wound characteristics
- Size and approximation
- Drainage (amount and characteristics)
- Inflammation and discoloration
- Pain
- Odor
Interventions for health promotion
- Nutrition and fluid intake
- Pressure redistribution
- Incontinence care
- Repositioning and mobility
- Use of mobility devices
Purpose of wound dressings
- Protect the wound from microorganisms and contamination
- Aid in hemostasis
- Promote healing through absorption and debridement
- Support or splint wound site
wound dressing considerations
- Can it be changed or reinforced
- Can clean or sterile technique be used
- How is the dressing secured
- How are the materials disposed of
- Who will be changing the dressings at home
removing old dressings
- Assess the patient’s pain
- Prepare for procedure, apply PPE
- Remove adhesive, and remove old dressing one layer at a time. Observe all drainage
- Dispose of gloves and soiled dressing
- Assess and palpate wound
securing dressings
- Rolled gauze
- tape
- abdominal binder
- adhesive ties
- tubigrip
Debridement
- removal of dead tissue to promote the healing of healthy tissues
- Types: mechanical, autolytic, chemical/enzymatic, biological, sharp/surgical
drain removal
- Assess pain
- Remove drain suction, remove sutures and staples
- Instruct the patient to take deep breaths, stabilize the surrounding skin with a gauze pad, and swiftly/evenly withdraw the drain
- Inspect drain components to make sure it is fully intact
insulin
allows glucose to enter cells, secreted from the pancreas
glucose
source of energy for cells that make up muscles and other tissues, sourced from food and liver
diabetes mellitus
- Type 1: no insulin is produced
- Type II: insulin resistance
Fasting plasma glucose
- Pre-diabetes - 100-125
- Type I or II - > 126
Oral glucose tolerance
- Pre-diabetes - 140-199
- Type I or II - > 200
diabetes s/s
- Increased hunger and thirst
- Frequency
- Unexplained weight loss
- Irritability and mood changes
type I risk factors
family history, genetics, geography, age
type II risk factors
overweight, obesity, inactivity, family history, race/ethnicity, blood lipid levels, age, pre-diabetes/gestational diabetes
pre-diabetes risk factors
- Overweight, obese, large waist size
- Poor diet or inactivity
- Age
- Family history
- Race and ethnicity
- Gestational diabetes
- Polycystic ovary syndrome
- Obstructive sleep apnea
- Smoking
Gestational diabetes risk factors
- Overweight or obese
- Inactivity
- Large birth weight
- Social determinants of health
- Race or ethnicity
rapid-acting insulin
types - aspart, lispro, glulisine
onset - 15 mins
peak - 1-3 hours
duration - 3-5 hours
short-acting insulin
types - regular or human
onset - 30 mins
peak - 2-4 hours
duration - 5-8 hours
intermediate-acting insulin
types - NPH
onset - 15 mins - 4 hrs
peak - 14-12 hours
duration - 16-24 hours
long-acting insulin
types - glargine, detemir, degludec
onset - 1-2 hours
peak - 6-12 hours
duration - 24 hours
Complications of insulin use
- Hypoglycemia
- hyperglycemia
- insulin resistance
- dawn phenomenon
- Somogyi effect
Insulin storage and safety
Store in fridge, keep out of direct sunlight, check expiration date, examine vials
Syringe storage and safety
Cleanse skin before administering
Do not reuse or share
Keep needles clean
