Module 4 Part two Flashcards
open or closed tissue injury
disruption of normal anatomic structure or function that results from bodily injury or a pathological process
wound
disruption or break in the skin
open
no disruption or break in the skin
closed
free of infectious and potentially infectious microbes
clean
wound with microbes
infected
contaminated
break in epidermis, dermis or underlying tissue
penetrating
superficial injury caused by rubbing and scrapping
abrasion
open wound with jagged edge
laceration
what are the signs of wound infection
accumulation of fluid and RBCs
loss of function
draining
wound dehiscence
what symptoms occur when infection wound
erythema edema heat pain function
what is the wound assessment
REEDA
redness, edema, ecchymosis, draining, approximation
what are risk factors of pressure ulcers
old age, contractures, diabetes, immobility, incontinence, impaired circulation, obesity, vascular disease
what does the braden scale measure
sensory perception, moisture, activity, mobility, nutrition, and friction
how to check for pressure ulcers
assess bony prominences
transverse depressions of nails
Beau’s lines
elevated ridges, common in elderly
longitudinal ridges
white spots in the nail plate
leukonychia punctata
red swelling of nail fold
paronychia
what are developmental variations in newborns
first few hours may be red
dark skinned don’t always manifest coloration (except in nail bed and scrotal)
developmental variations in neonatal
acrocyanosis, erythema toxicum, harlequin color changes, Mongolian spots, telangiectasis, physiologic jaundice, milia
stork bite
telangiectasis
pink papular rash on neonatal
erythema toxicum
cyanosis of hands and feet
acrocyanosis
developmental variations in pregnancy
striae gravidarum, linea nigra, chloasma, darkening of moles, palmar erythema
developmental variations in older adults
transparent skin, dry skin, wrinkling/drooping, cherry angiomas, seborrheic keratosis, senile lentigines
orientation
what is the year, season, date, day, month
where are we state, country, town, hospital, floor
registration
name three objects and patient must repeat them
attention and calculation
serial sevens (stop after 5)
recall
ask for the three objects repeated from above
language
1) name a pencil and watch
2) repeat the following
3) follow 3 stage command
4) read and obey the following (close your eyes)
5) write a sentence
6) copy and design a trapeze
