Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

n232 > module 2: wound care > Flashcards

module 2: wound care Flashcards

1
Q

who are prone to ulcers?

A
  • pts confined to bed for long periods of time
  • motor or sensory dysfunction
  • pt who may experience muscular atrophy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what are pressure ulcers?

A

localized areas of infarcted soft tissue that occur when pressure is applied to the skin over time is greater than normal capillary closure pressure (about 25-32mmHg)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

critically ill pt have lower capillary closure pressure thus?

A

are at greater risks of pressure ulcers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

initial sign of pressure ulcers

A

-erythema caused by hypermia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

unrelieved pressure results in?

A

further skin breakdown

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

assessment of pressure ulcers/skin breakdown?

A
  • immobility
  • impaired sensory perception or congition
  • decreased tissue perfusion
  • decreased nutritional status
  • friction and shear forces
  • increased moisture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

geriatric and skin breakdown?

A
  • older adults have a number of age-related chances that increase the risk (reduced skin elasticity, decreased collagen, muscle/tissue atrophy
  • decreased inflm response
  • little subcutaneous padding over bony prominences
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

definition of would?

A

any disruption to the layers of the skin and underlying tissues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

types of wound healing?

A

primary intention
secondary intention: left to close with scar tissue
tertiary intention: left open for a long period of time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

trajectory of wound healing?

A
  • hemostasis: 1-4 days, sending cells to site, want it to stop bleeding
  • inflammation: up to 4 days, trying to get bacteria out of the wound
  • proliferation: longer stage, 4-21 days, affected by inadequate nutrition
  • remodelling: can take up to 2 years until all scar tissue is completely formed and healed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

all wounds start as?

A

acute

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

acute wound=

A

wound that heals within an expected time frame (within 21 days_

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what is a chronic wound?

A

one that in which the normal process of wound healing is disrupted at one or more points in the phases of wound healing, long duration reoccurs frequently

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

stage 1 pressure ulcer?

A
  • redness, skin still intact

- only affecting top layer, no dermis yet, no breakage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

stage 2 pressure ulcer?

A

goes into dermis layer, skin starting to break

-primary prevention now gone,risk to infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

stage 3 pressure ulcer?

A
  • damage of subcutaneous layer, may see some subcutaneous fat
  • drainage, open- note the colour, surrounding skin
17
Q

stage 4 pressure ulcer?

A

all the way through to muscle, bone, tendons

-definite drainage

18
Q

unstageable pressure ulcer?

A
  • ulcer is covered by slough or eschar

- usually requires advanced interventions

19
Q

what is wound dehiscence?

A

distressing but common occurrence among patients who have received sutures. The condition involves thewoundopening up either partially or completely along the sutures – thewoundreopens to create a newwound.

20
Q

risk factors for pressure ulcers?

A
  • prolonged pressure on tissue
  • immobility
  • loss of protective reflexes
  • poor skin perfusion
  • malnutrition, hypoproteinemia, anemia, vit def., friction, incontinence, alterred skin moisture, advanced age, equipment (casts), critcally ill patients
21
Q

arterial disorder?

A

arteriosclerosis

atherosclerosis

22
Q

what is arteriosclerosis?

A
  • most common disease of the arteries “hardening of the arteries”
  • muscle fibers and walls of small arteries and arterioles become thickened
23
Q

what is atherosclerosis?

A

-affects the intima of large and medium sized arteries
-change consists of accumulation of lipids, calcium, blood components, carbs, fibres on intimal layer
(referred to as atheromas or plaques)

24
Q

most common result of atherosclerosis?

A

narrowing (stenosis) of the lumen, obstruction by thrombosis, aneurysm, ulceration

25
Q

indirect result of atherosclerosis?

A

-malnutrition, subsequent fibrosis

26
Q

risk factors to atherosclerosis?

A
  • tobacco
  • nicotine
  • carbon monoxide
  • obesity, stress, lack of exercise
  • elevated BP, family history
27
Q

prevention of atherosclerosis?

A
  • dont eat high fat diet
  • diet modifiation
  • measure cholesterol
  • LDL below 2mmol per L
28
Q

nursing management for atherosclerosis: improving peripheral arterial circulation

A
  • applying warmth
  • avoid exposure to cold temp
  • adequate clothing to maintain warmth
  • warm bath or drink
  • hot water bottle or pad on abdomen
29
Q

relieving pain from atherosclerosis?

A

oxycodone plus aspirin and acetaminophen may be helpful

30
Q

pressure ulcer interventions?

A
  • maintain good skin hygiene, avoid skin trauma
  • provide supporting devices
  • frequent positioning
  • multidisciplinary approach
  • provide local wound care
31
Q

what are lower limb ulcers? caused by?

A
  • distinct from pressure ulcers
  • caused by diabetes or arterial or venous insufficiency
  • assessment and treatment: aided by doppler ultrasounds, compression dressings, interdisciplinary approach
32
Q

characteristics of venous ulcers?

A
  • 75% caused by chronic venous insufficency
  • dull aching or heavy
  • edema
  • typically large
  • irregular ulcer border
  • highly exudative
  • pulses present
  • bleeds easily
  • location: gaiter area
33
Q

venous ulcer prevention?

A

-compression of extremity, protect from trauma, keep clean, dry, soft, wound management

34
Q

arterial ulcer characteristics?

A
  • 20% of leg ulcers due to arterial insufficency
  • claudication
  • digital or forefoot pain at rest
  • smooth/regular shaped borders
  • typically small, circular, deep
  • minimal drainage
  • non bleeding
  • pulse weak or not palpable
  • pale or black
  • location: toes, heels, skin, medial side of hallux
35
Q

arterial ulcer intervention?

A

eliminate restrictive clothing

  • protect extremities from cold and trauma
  • apply warmth
  • elevate head of bed to maintain lower leg position below level of heart
  • support client to supervised exercise program
36
Q

diabetic foot ulcers? why?

A

-hyperglycemia, motor neuropathy, sensory neuropathy, PVD

37
Q

what is chronic venous insufficency

A

results from obstruction of venous valves in the legs or a reflux of blood through the valves
-walls of veins are thinner and more elastic, distend readily when pressure elevated

n232 (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions