shit im screwed Flashcards
What does ADPIE stand for?
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment of ADPIE
Gathering patient data
- medical history
- vital signs
- s/s
Diagnosis of ADPIE
identifying the pt.s health problems based on the assessment
eg. dehyration related to fever, as evidenced by dry skin and reduced fluid intake
Planning of ADPIE
Creating a care plan with specific goals and interventions
Plan:
- encourage pt. to drink more fluids
- give meds
Implementations of ADPIE
carrying out the planned interventions
- administering fluids/meds
- pt. remined to drink water regularly
Evaluation of ADPIE
checking if the interventions worked and adjusting the care plan if needed
eg. after 48hrs, pt.s fever has increased to 39.2C, the redness has spread, and theres more drainage. Pain is now 9/10.
Plan?
- contact doctor for stronger antibiotic
- increase IV fluids to fight infections
Stages of Healing
Hemostasis (Immediate Response)
Inflammatory Phase (0-4 days)
Proliferative Phase (4-24 days)
Maturation (Remodeling) Phase (21 days - 2 years)
Hemostasis
Immediate Response
Occurs within minutes after injury.
Blood vessels constrict to stop bleeding (vasoconstriction), and platelets form a clot.
Fibrin helps create a stable clot to prevent further blood loss.
Inflammatory Phase
0-4 days
White blood cells (especially neutrophils and macrophages) rush to the site to clear bacteria and debris.
Redness, swelling, heat, and pain occur as the body fights infection and begins repair.
Proliferative Phase
4-24 days
Fibroblasts produce collagen, forming new tissue.
Granulation tissue (pink, beefy-looking tissue) fills the wound.
New blood vessels (angiogenesis) develop to bring oxygen and nutrients.
The wound starts to contract as epithelial cells migrate to cover it.
Maturation Phase
Remodeling (24 days - 2 years)
Collagen is reorganized and strengthened to form scar tissue.
The wound gains strength but will never be as strong as uninjured skin (max ~80% original strength).
What is a stage 1 pressure ulcer?
is characterized by non-blanchable erythema of intact skin. It appears red and does not turn white when pressed.
What are the characteristics of a Stage 2 pressure ulcer?
involves partial-thickness loss of dermis, presenting as a shallow, open ulcer with a red-pink wound bed without slough or eschar. It may appear as a blister.
A patient has a wound that extends into the subcutaneous tissue, with slough or eschar visible in the wound bed. Which stage is this wound?
This is a Stage 3 pressure ulcer, which involves full-thickness loss of skin, extending into the subcutaneous tissue but not through the underlying fascia.
What defines a Stage 4 pressure ulcer?
involves full-thickness tissue loss, with exposed bone, tendon, or muscle. There may be slough or eschar present in the wound bed.
A wound has thick, dry, leathery tissue that covers the wound. Is it considered Stage 3 or Stage 4?
The wound is Stage 4 if the underlying tissue is exposed, and eschar (dry, necrotic tissue) is present. If the eschar covers the wound bed and doesn’t expose underlying structures, it is considered unclassified until further evaluation.
What happens during the inflammatory phase of wound healing?
During the inflammatory phase (0–4 days), the body works to stop the bleeding, clear debris, and fight infection.
Redness, heat, swelling, and pain occur as blood vessels dilate and white blood cells rush to the site.
A patient has just had a surgical wound. It is red, swollen, and painful, but the tissue around the wound is not broken down. What phase of healing is this patient in?
This patient is in the inflammatory phase. The signs of redness, swelling, and pain indicate the body’s natural response to injury and the start of the healing process.
What is the main goal of the proliferative phase of wound healing?
The goal of the proliferative phase (4–24 days) is to fill and cover the wound with new tissue, called granulation tissue. New blood vessels form, and the wound starts to contract as epithelial cells cover the wound bed
A patient’s surgical wound is healing, and new tissue is forming at the edges. The wound is less swollen, and the tissue looks pink and moist. What phase of healing is this?
The patient is in the proliferative phase. The pink, moist granulation tissue and the contraction of the wound indicate the tissue is healing and starting to close.
What is the main purpose of the maturation phase of wound healing?
The main purpose of the maturation phase (21 days to 2 years) is to strengthen and remodel the collagen in the wound. Scar tissue is formed, and the wound gradually gains strength, but it will never be as strong as the original tissue.
How long does the maturation phase of wound healing typically last?
The maturation phase typically lasts from 21 days to 2 years, depending on the severity and location of the wound.
A patient with a chronic wound has shown little to no progress in healing despite several weeks of treatment. The wound is still inflamed, and there’s noticeable tissue breakdown. What might need to be changed in the care plan?
The patient may be stuck in the inflammatory phase, possibly due to infection, poor nutrition, or inadequate wound care. The care plan should be adjusted to include wound culture to check for infection, nutritional support, and possibly a referral to a wound care specialist for better management.
A patient’s wound has healed and formed a scar. The scar looks pale, and the tissue around it is firm but not red or swollen. What phase of healing is this?
This patient is in the maturation phase, where the wound has closed, and the scar tissue is maturing and becoming stronger over time.
