NRSG200 > QUIZ 9 > Flashcards
QUIZ 9 Flashcards
T1 to T12
thoracic vertebrae, one to twelve
T&A
tonsillectomy and adenoidectomy
t/o
telephone order
TAH
total abdominal hysterectomy
TB
tuberculosis
TBI
traumatic brain injury
TC&DB
turn, cough, and deep breathe
TEE
transesophageal echocardiogram
TF
tube feeding
TIA
transient ischemic attack
tid
three times a day
TKO
to keep open
TPA
tissue plasminogen activator
TPN
total parenteral nutrition
TPR
temperature, pulse and respiration
TSH
thyroid stimulating hormone
TURP
transurethral resection, prostate
U/A
urinalysis
UAP
unlicensed assistive personnel
UE
upper extremity
U/O
urinary output
URI
upper respiratory infection
UTI
urinary tract infection
approximated
tissue surfaces around a wound have closed.
debridement
black pressure wounds are covered which eschar and need debridement, which is removal of necrotic material. removal must occur before the wound can be staged or healed. debridement can be done sharp (scalpel or scissors to separate dead tissue), mechanical (scrubbing or damp dressings), chemical (more selective than sharp and mechanical, uses collagenase enzyme agents like papain-urea), or autolytic (dressings such as hydrocolloid and clear absorbent acrylic dressings trap wound drainage against eschar and bodys own enzymes in drainage break down necrotic tissue. it takes longer but is most selective and causes least damage to healthy surrounding tissue).
fly larvae can be very effective in cleansing chronic wounds.
dehiscence
partial or total rupturing of a sutured wound. usually involves an abdominal wound in which the layers below the skin also separate. a number of factors, including obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, dehydration heighten a client’s risk of wound dehiscence. more likely to occur 4-5 days post op before extensive collagen is deposited in the wound.
sudden straining like coughing or sneezing may precede this. not unusual for client to feel like “something has given way”.
wound must be quickly supported by large sterile dressings soaked in sterile normal saline, client is placed in bed with knees bent to decrease pull on incision, surgeon is notified immediately because surgical repair may be necessary.
epithelial tissue
has a good regenerative capacity if underlying support structure is intact. (reparative phase)
eschar
if a wound does not close by epithelialization, the area becomes covered with dried plasma protein and dead cells, which is eschar.
excoriation
area of loss of superficial layers of the skin; also known as denuded.
digestive enzymes in feces, urea in urine, and gastric tube drainage also contribute to skin excoriation. any accumulation of secretions or excretions is irritating to skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection.
exudate
material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces. nature and amount of exudate vary according to the tissue involved, the intensity and duration of inflammation, and presence of microorganisms.
3 major types: serous (serum of blood, watery as in blister), purulent (thicker, pus with leukocytes and dead/living bacteria and dead tissue debris, blue/green/yellow), and sanguineous (large amounts of RBCs from damage to capillaries, common in open wounds).
evisceration
protrusion of the internal viscera through an incision.
wound must be quickly supported by large sterile dressings soaked in sterile normal saline, client is placed in bed with knees bent to decrease pull on incision, surgeon is notified immediately because surgical repair may be necessary.
granulation tissue
this tissue forms during wound healing in the proliferative phase.
capillaries grow across the wound, increasing the blood supply. fibroblasts move from the blood stream into the wound, depositing fibrin. as the capillary network develops, the tissue becomes a translucent red. this tissue is granulation tissue and is fragile and bleeds easily. when skin edges of a wound are not sutured, the area must be filled with granulation tissue.
hematoma
localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise). large hematoma may be dangerous in that it places pressure on blood vessels and other structures and can thus obstruct flow.
hemostasis
cessation of bleeding: results from vasoconstriction of larger blood vessels in the affected area, retraction of injured blood vessels, deposition of fibrin, and formation of blood clots.
ischemia
deficiency in blood supply to the tissue. when tissue is compressed between two surfaces, blood cannot reach tissue, cells are deprived of o2 and nutrients, waste products of metabolism accumulate, and the tissue dies.
localized ischemia is what causes pressure ulcers.
keloid
this may form in wound healing during the maturation phase.
during maturation, the wound is remodeled and contracted. the scar becomes stronger but the repaired area is never as strong as the original tissue. in some individuals, especially dark-skinned individuals, an abnormal amount of collagen is laid down. this can result in a hypertrophic scar, or keloid.
maceration
moisture from incontinence promotes skin maceration, which is tissue softened by prolonged wetting or soaking, making the epidermis more easily eroded and susceptible to injury.
pressure ulcer – new terminology is pressure injury
consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement. due to localized ischemia. tissue dies, and prolonged unrelieved pressure can also damage small blood vessels.
pressure ulcers were also known as decubitus ulcers, pressure sores, bedsores.
pressure ulcers are preventable. development of stage III or IV or unstageable are considered serious reportable events.
-partial thickness: involves skin (dermis and epidermis), heal by regeneration
-full thickness: involve dermis, epidermis, subcutaneous tissue, possibly muscle and bone, require connective tissue repair.
primary intention healing
tissues have been approximated and there is minimal or no tissue loss; characterized by minimal granulation tissue and scarring.
aka primary union or first intention healing.
example: closed surgical incision, use of tissue adhesive (liquid glue that can be used to seal clean lacerations or incisions and may result in less noticeable scars)
reactive hyperemia
when skin has been compressed it appears pale but when later the pressure is relieved, the skin takes on a bright red flush, called reactive hyperemia.
secondary intention healing
wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated heals by secondary intention healing.
differs from primary intention healing:
1. repair time is longer
2. scarring is greater
3. susceptibility to infection is greater
ex: pressure ulcer.
shearing force
a combination of friction and pressure.
occurs commonly when client assumes sitting position in bed: in this position, body tends to slide down toward foot of bed –> this movement is transmitted to sacral bone and deep tissues, but skin over sacrum tends not to move because of adherence between skin and bone. the skin and superficial tissues are thus relatively unmoving in relation to the bed surface, whereas the deeper tissues are firmly attached to the skeleton and move downward. this causes shearing force in area where deeper tissues and superficial tissues meet. this force damages blood vessels and tissues in the area.
tertiary intention
wounds that are left open for 3-5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures heal by tertiary intention, aka delayed primary intention.
vasodilation
process in which extra blood floods to the area to compensate for the preceding period of impeded blood flow after extended pressure on skin.
