Skin Integrity and Wound Care Flashcards
presence of normal skin and skin later uninterrupted by wounds
intact skin
what are the factors that affect skin integrity?
genetics and integrity, age, underlying health, activity, illnesses, medications
occurs during therapy, examples are operations or venipuncture
intentional trauma
accidental; examples are fracture
unintentional wounds
tissues are traumatized without a break in the skin
closed wounds
skin or mucous membrane surface is broken
open wounds
uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered; primarily closed wounds.
clean wounds
surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered; show no evidence of infection
clean-contaminated wounds
include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract; show evidence of inflammation
contaminated wounds
include wounds containing dead tissue and wounds with evidence of a clinical infection
Dirty or infected wounds
confined to the skin (dermis and epidermis), and can be healed by regeneration
Partial thickness
involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone, and require connective tissue repair
Full thickness
caused by a sharp instrument
incision
blow from a blunt instrument
contusion
surface scrape, either unintentional or intentional
abrasion
penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional
puncture
tissues torn apart often from accidents
laceration
penetration of the skin and the underlying tissues, usually unintentional
penetrating wound
injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement; previously called decubitus ulcers, pressure sores, or bedsores; due to localized ischemia
Pressure ulcers
bright red flush that occurs when pressure is relieved from the skin; usually lasts one half to three quarters as long as the duration of impeded blood flow; If the redness disappears in that time, no tissue damage is anticipated. If, however, the redness does not disappear, then tissue damage has occurred
reactive hyperemia
friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decrease mental status, diminished sensation, excessive body heat, advanced age, chronic medical conditions, poor lifting and transferring techniques, incorrect positioning, hard support surfaces, and incorrect application of pressure-relieving devices are risk factors for what?
pressure ulcers
a force acting parallel to the skin surface; can abrade the skin, that is, remove the superficial layers, making it more prone to breakdown
Friction
a combination of friction and pressure; occurs commonly when a client assumes a sitting position in bed
Shearing force
a reduction in the amount and control of movement a person has
Immobility
What three conditions reduce the amount of padding between the skin and the bones, thus increasing the risk of pressure ulcer?
Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue
abnormally low protein content in the blood
hypoproteinemia
presence of excess interstitial fluid; increases the distance between the capillaries and the cells, thereby slowing the diffusion of oxygen to the tissue cells and of metabolites away from the cells
edema
tissue softened by prolonged wetting or soaking
maceration
area of loss of the superficial layers of the skin; also known as denuded area
excoriation
TRUE OR FALSE: moisture from the incontinence makes the epidermis more easily eroded and susceptible to injury, digestive enzymes in feces, urea in urine, and gastric tube drainage also contribute; accumulation of secretions or excretions is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection
TRUE
WHAT STAGE OF PRESSURE ULCER IS THIS: nonblanchable erythema signaling potential ulceration
stage I of pressure ulcer
WHAT STAGE OF PRESSURE ULCER IS THIS: partial-thickness skin loss involving the epidermis and possibly the dermis
stage II of pressure ulcer
WHAT STAGE OF PRESSURE ULCER IS THIS: full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; presents clinically as a deep crater with or without undermining of adjacent tissue
stage III of pressure ulcer
WHAT STAGE OF PRESSURE ULCER IS THIS: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures
stage IV of pressure ulcer
WHAT STAGE OF PRESSURE ULCER IS THIS: full-thickness skin or tissue loss—depth unknown: actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed
unstageable/unclassified
WHAT STAGE OF PRESSURE ULCER IS THIS: depth unknown; purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear; eep tissue injury may be difficult to detect in individuals with dark skin tones
suspected deep tissue injury
what are the two risk assessment tools for pressure ulcers?
Braden Scale for Predicting Pressure Sore Risk, and Norton’s Pressure Area Risk Assessment Scoring System
what pressure ulcer risk assessment tool consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear, and where a total of 23 points is possible and an adult who scores below 18 points is considered at risk?
Braden Scale for Predicting Pressure Sore Risk
what pressure ulcer risk assessment tool includes the categories of general physical condition, mental state, activity, mobility, and incontinence; category of medications is added by some users, resulting in a possible score of 24, and where scores of 15 or 16 should be viewed as indicators, not predictors, of risk?
Norton’s Pressure Area Risk Assessment Scoring System
begins immediately after injury and lasts 3 to 6 days, and involves 2 major processes: hemostasis and phagocytosis
inflammatory phase
cessation of bleeding; results from vasoconstriction of the larger blood vessels in the affected area, retraction (drawing back) of injured blood vessels, the deposition of fibrin (connective tissue), and the formation of blood clots in the area
hemostasis
may form on the surface of the wound, consists of clots and dead and dying tissue, and serves to aid hemostasis and inhibit contamination of the wound by microorganisms
scab
located below the scab, migrates into the wound from the edges, and serve as a barrier between the body and the environment, preventing the entry of microorganisms
epithelial cells
what does vascular and cellular responses do?
intend to remove any foreign substances and dead and dying tissues
_______ migrate into the interstitial space, and are replaced about 24 hours after injury by ________
leukocytes; macrophages
process in which macrophages engulf microorganisms and cellular debris
phagocytosis
secreted by macrophages, which stimulates the formation of epithelial buds at the end of injured blood vessels
angiogenesis factor
sustains the healing process and the wound during its life; this response is essential to healing
microcirculatory network
second phase in healing, extends from day 3 or 4 to about day 21 postinjury; fibroblasts (connective tissue cells), which migrate into the wound starting about 24 hours after injury, begin to synthesize collagen
proliferative phase
_______ grow across the wound, increasing the blood supply, and fibroblasts move from the bloodstream into the wound, depositing fibrin
capillaries
begins on about day 21 and can extend 1 or 2 years after the injury; fibroblasts continue to synthesize collagen; the wound is remodeled and contracted, and scar becomes stronger but the repaired area is never as strong as the original tissue
Maturation phase
assigns scores to the ulcer length, width, amount of exudate, and tissue type; the change in the total score over time can be used as an indication of healing
Pressure Ulcer Scale for Healing (PUSH) tool
_________ is when microorganisms are in the wound surface, and compete with new cells for oxygen and nutrition, and produce by products that can interfere with a healthy surface condition
colonization
what are the factors that affect wound healing?
age, nutritional status, lifestyle, and medications
growing only in the presence of oxygen; generally found on the surface of the wound
aerobic (organisms)
growing only in the absence of oxygen; found in deep wounds, tunnels, and cavities
anaerobic (organisms)
______ means closed
approximated
strip of cloth used to wrap some part of the body
bandage
type of bandage designed for a specific body part
binder
whitish protein substance that adds tensile strength to the wound; as the amount of collagen increases, so does the strength of the wound
collagen
reduces the swelling and keeps blood moving more efficiently in the injured area
compress
removal of the necrotic material
debridement
partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate
dehiscence
wound that does not close by epithelialization, and area becomes covered with dried plasma proteins and dead cells
eschar
protrusion of the internal viscera through an incision
evisceration
area of loss of the superficial layers of the skin; also known as denuded area
excoriation
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
exudate
tissue that has translucent red color, is fragile and bleeds easily, that results from development of a capillary network
granulation tissue
a localized collection of blood underneath the skin that may appear as a red- dish blue swelling (bruise)
hematoma
massive bleeding; a dislodged clot, a slipped stitch, or erosion of a blood vessel may cause severe bleeding
hemorrhage
a deficiency in the blood supply to the tissue
ischemia
a hypertrophic scar, that results from abnormal amount of collagen
keloid
internal direct pressure that places gauze material directly on the lacerated blood vessels in an attempt to control bleeding
packing
tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; formation of minimal granulation tissue and scarring; it is also called primary union or first intention healing
primary intention healing
thicker than serous exudate because of the presence of pus; vary in color depending on causative organism
purulent exudate
consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria
pus
quality of living tissue; also known as healing
regeneration
large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma
sanguineous exudate
consisting of both clear and blood-tinged drainage, is commonly seen in surgical incisions
seroanguineous exudate
consisting of pus and blood, is often seen in a new wound that is infected
purosanguineous discharge
wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated; repair time is longer, scarring is greater, susceptibility to infection is greater
secondary intention healing
blood-tinged drainage
serosanguineous
consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum; looks watery and has few cells; an example is the fluid in a blister
serous exudate
used to soak a client’s perineal or rectal area
sitz bath
process of pus formation
suppuration
wounds that are left open for 3 to 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; also called delayed primary intention
tertiary intention
reduces blood flow to the affected area and thus reduces the supply of oxygen and metabolites, decreases the removal of wastes, and produces skin pallor and coolness
vasoconstriction
extra blood floods to the area to compensate for the preceding period of impeded blood flow
vasodilation
TRUE OR FALSE: Removing barriers to assessment is very important—Antiembolic stockings, braces, or devices must be removed to assess the skin condition underneath
TRUE
TRUE OR FALSE: Assessing skinfolds such as under the breasts, in areas that are frequently moist such as the perineum, and in areas that receive extensive pressure are not necessary
FALSE—Particular attention is paid to skin condition in those areas since they are most likely to break down
usually seen shortly after an injury
Untreated wounds
usually assessed to determine the progress of healing
Treated wounds or sutured wounds
only stains the dressing
Minimal drainage
saturates the dressing without leakage
Moderate drainage
overflows the dressing prior to scheduled change
Heavy drainage
when the wound reaches under the skin surface, and can result in a sinus tract or tunnel
undermining
To measure wound _______ is to place a second swab parallel to the first and measure the distance from the edge of the wound to the tip of the exposed swab
depth
ASSESSING WOUND: should the nurse should assess location and extent of tissue damage, inspect wound for bleeding, control severe bleeding, and assess associated injuries?
YES
ASSESSING WOUND: if wound is contaminated, the nurse shouldn’t determine when the client last had a tetanus toxoid injection. Is this correct?
NO
ASSESSING WOUND: should the nurse prevent infection by cleaning or flushing with normal saline and covering wound with a clean dressing if possible, control swelling and If bleeding is severe or if internal bleeding is suspected, and assess the client for signs of shock?
YES
TRUE OR FALSE: the easiest and most accurate method of documenting wound size and shape is with disposable wound-measuring guides
TRUE
For irregularly shaped wounds, the nurse can use two layers of _________
transparent film
To measure an area located on a curved portion of the body, the nurse must use a __________
flexible measure
LAB VALUES: decreased ___________ can delay healing and increase the possibility of infection
leukocyte count
LAB VALUES: ___________ below the normal range indicates poor oxygen delivery to the tissues
hemoglobin level
LAB VALUES: ___________ can result in excessive blood loss and prolonged clot absorption
prolonged coagulation times
LAB VALUES: __________ can lead to intravascular clotting, and result in a deficient blood supply to the wound area
Hypercoagulability
LAB VALUES: ____________ provides an indication of the body’s nutritional reserves for rebuilding cells
Serum protein analysis
LAB VALUES: ___________ is an important indicator of nutritional status (below 3.5 g/dL indicates poor nutrition)
Albumin
LAB VALUES: ___________ can either confirm or rule out the presence of infection
Wound cultures
LAB VALUES: __________ are helpful in the selection of appropriate antibiotic therapy
Sensitivity studies
WHAT DIAGNOSIS: vulnerable to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear
Risk for Pressure Ulcer
WHAT DIAGNOSIS: vulnerable to alteration in epidermis and/or dermis which may compromise health.
Risk for Impaired Skin Integrity
WHAT DIAGNOSIS: altered epidermis and/or dermis
Impaired Skin Integrity
WHAT DIAGNOSIS: damage to mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament
Impaired Tissue Integrity
WHAT DIAGNOSIS: if the skin impairment is severe, the client is immunosuppressed, or the wound is caused by trauma
Risk for Infection
WHAT DIAGNOSIS: related to nerve involvement within the tissue impairment or as a consequence of procedures used to treat the wound
Acute Pain
what are the two major goals for clients at Risk for Impaired Skin Integrity?
to maintain skin integrity and to avoid potential associated risks
what are the two major goals for clients with Impaired Skin Integrity?
demonstrate progressive wound healing and regain intact skin within a specified time frame
TRUE OF FALSE: Increasingly, wound care is provided in the home rather than in health care facilities.
TRUE
what are the nursing interventions for maintaining skin integrity and wound care?
supporting wound healing, preventing pressure ulcers, treating pressure ulcers, dressing and cleaning wounds, supporting and immobilizing wounds, and applying heat and cold
- SUPPORTING WOUND HEALING: The dressing and frequency of change should support _______ wound bed conditions. Wound beds that are too _______ or disturbed too often fail to heal
moist; dry
SUPPORTING WOUND HEALING: Clients should be assisted to take in at least ________ mL of fluids a day unless conditions contraindicate this amount
2,500
SUPPORTING WOUND HEALING: sufficient protein, vitamins _, _, __, __, and zinc are important
C, A, B1, B5
- SUPPORTING WOUND HEALING: what are the two main aspects to controlling wound infection?
preventing microorganisms from entering the wound, and preventing the transmission of bloodborne pathogens to or from the client to others
SUPPORTING WOUND HEALING: what is the position that keep pressure off the wound?
off-loading
SUPPORTING WOUND HEALING: client should be assisted to be as ________ as possible because activity enhances circulation
mobile
PREVENTING PRESSURE ULCERS, TRUE OR FALSE: identifying clients at risk, and reliably implementing prevention strategies for all clients who are identified as being at risk, should be done.
TRUE
PREVENTING PRESSURE ULCERS: _________ intake of calories, protein, vitamins, and iron is believed to be a risk factor for pressure ulcer development
inadequate
- PREVENTING PRESSURE ULCERS: what are the three pertinent lab work that should be monitored?
lymphocyte count, protein (especially albumin), and hemoglobin
PREVENTING PRESSURE ULCERS, TRUE OR FALSE: When bathing the client, the nurse should minimize the force and friction applied to the skin, using mild cleansing agents that minimize irritation and dryness and that do not disrupt the skin’s “natural barriers.”
TRUE
PREVENTING PRESSURE ULCERS: avoid using ____ water, which increases skin dryness and irritation.
hot
- PREVENTING PRESSURE ULCERS: Nurses can minimize dryness by avoiding exposure to ________ and _____ humidity
cold; low
- PREVENTING PRESSURE ULCERS, TRUE OR FALSE: Dry skin is best treated with moisturizing lotions applied while the skin is moist after bathing
TRUE
PREVENTING PRESSURE ULCERS, TRUE OR FALSE: client’s skin should be kept in contact with urine, feces, sweat, and incomplete drying after a bath is alright
FALSE—client’s skin should be clean and dry and free of irritation and maceration
PREVENTING PRESSURE ULCERS, TRUE OR FALSE: Providing the client with a smooth, firm, and wrinkle-free foundation on which to sit or lie helps prevent skin trauma
TRUE
PREVENTING PRESSURE ULCERS: shearing force can be reduced by elevating the head of the bed to no more than ___, if this position is not contraindicated by the client’s condition
30°
PREVENTING PRESSURE ULCERS: __________ and _________ are never used as friction or moisture prevention
Baby powder; cornstarch
PREVENTING PRESSURE ULCERS, TRUE OR FALSE: Frequent shifts in position, even if only slight, effectively change pressure points. The client should shift weight 10° to 15° every 15 to 30 minutes and, whenever possible, exercise or ambulate to stimulate blood circulation
TRUE
PREVENTING PRESSURE ULCERS, TRUE OR FALSE: it’s alright for nurses to not use a lifting device, such as a trapeze, in moving patient
FALSE—nurses should use a lifting device rather than dragging the client across or up in bed
PREVENTING PRESSURE ULCERS: Any at-risk client confined to bed—even when a special support mattress is used—should be repositioned at least every ___________, depending on the client’s need,
2 hours
PREVENTING PRESSURE ULCERS: massage over bony prominences is ideal, and promotes healing
FALSE—it should be avoided
PREVENTING PRESSURE ULCERS, TRUE OR FALSE: pressure on bony prominences can be relieved through a combination of turning, positioning, and use of pressure-relieving surfaces
TRUE
PREVENTING PRESSURE ULCERS: _____________ provide continuous passive motion or oscillation therapy, which is intended to counteract the effects of a client’s immobility
Kinetic beds
PREVENTING PRESSURE ULCERS: _______________ should not be used since they limit blood flow and can cause tissue damage to the areas in direct contact with the device
Doughnut-type devices
- PREVENTING PRESSURE ULCERS: _____________ Polyvinyl, silicone, or Silastic pads filled with a gelatinous substance similar to fat
Gel flotation pads
PREVENTING PRESSURE ULCERS: ____________ Supports positioning and offloads bone on bone contact.
Pillows and wedges
PREVENTING PRESSURE ULCERS: _________ Can raise or “float” a body part off the surface; prevent shearing and limit pressure on heel area
Heel protectors
PREVENTING PRESSURE ULCERS: __________ Polyurethane foam mattress distributes weight over bony areas evenly. Foam molds to the body
Memory foam mattress/chair pad
- PREVENTING PRESSURE ULCERS: ____________ Composed of a number of cells in which the pressure alternately increases and decreases; uses a pump
Alternating pressure mattress
PREVENTING PRESSURE ULCERS: __________ Support surface filled with water. Water temperature can be controlled.
Water bed
PREVENTING PRESSURE ULCERS: ___________ Consists of many air-filled cushions divided into four or five sections
Static low-air-loss (LAL) bed
PREVENTING PRESSURE ULCERS: ____________ Like the static LAL, but in addition gently pulsates or rotates from side to side, thus stimulating capillary blood flow and facilitating movement of pulmonary secretions.
Active or second-generation LAL bed
PREVENTING PRESSURE ULCERS: ___________ Forced temperature-controlled air is circulated around millions of tiny silicone-coated beads, producing a fluid-like movement.
Air-fluidized (AF) bed
based on the color of an open wound—red, yellow, or black (RYB)—rather than the depth or size of a wound
RYB color code
the goal of wound care are to: protect (cover)
red
the goal of wound care are to: cleanse
yellow
the goal of wound care are to: debride
black
Wounds that are _________ are usually in the ________________ of tissue repair need to be protected to avoid disturbance to regenerating tissue.
red; late regeneration phase
_______ wounds are characterized primarily by liquid to semiliquid “slough” that is often accompanied by purulent drainage or previous infection. The nurse cleanses these wounds to remove nonviable tissue
Yellow
________ wounds are covered with thick necrotic tissue, or eschar, and require debridement
Black
a scalpel or scissors is used to separate and remove dead tissue
sharp debridement
accomplished through scrubbing force or damp-to- damp dressings
Mechanical debridement
more selective than sharp or mechanical techniques; Collagenase enzyme agents such as papainurea are currently most recommended for this use
Chemical debridement
dressings such as hydrocolloid and clear absorbent acrylic dressings trap the wound drainage against the eschar. The body’s own enzymes in the drainage break down the necrotic tissue
autolytic debridement
When the eschar is removed, the wound is treated as ______, then _______
yellow; red
When more than one color is present, the nurse treats the most serious color first, that is, ______, then _______, then ________.
black; yellow; red
TYPES OF DRESSING: Adhesive plastic, semipermeable, nonabsorbent dressings allow exchange of oxygen between the atmosphere and wound bed. They are impermeable to bacteria and water.
transparent film
TYPES OF DRESSING: Woven or nonwoven cotton or synthetic materials are impregnated with petrolatum, saline, zinc-saline, antimicrobials, or other agents.
Impregnated nonadherent
TYPES OF DRESSING: Waterproof adhesive wafers, pastes, or powders,
hydrocolloids
TYPES OF DRESSING: has an inner adhesive layer that has particles that absorb exudates and form a hydrated gel over the wound; and an outer film that provides an occlusive seal.
wafers (hydrocolloids)
TYPES OF DRESSING: Transparent absorbent wafer designed to be worn 5–7 days. The acrylic layer absorbs exudates and evaporates the excess off the transparent membrane
clear absorbent acrylic
TYPES OF DRESSING: Glycerin or water-based nonadhesive jelly-like sheets, granules, or gels are oxygen permeable, unless covered by a plastic film
hydrogels
TYPES OF DRESSING: Nonadherent hydrocolloid dressings
polyurethane foams
TYPES OF DRESSING: Nonadherent dressings of powder, beads or granules, ropes, sheets, or paste conform to the wound surface and absorb up to 20 times their weight in exudate
alginates (exudate absorbers)
TYPES OF DRESSING: Gels, pastes, powders, granules, sheets, sponges derived from animal sources, often cow or pig
collagen
____________ dressings are often applied to wounds including ulcerated or burned skin areas
Transparent
_____________ dressings are frequently used over pressure ulcers
Hydrocolloid
___________ involves the removal of debris, and other microorganisms
Wound cleaning
____________ is the washing or flushing out of an area; Sterile technique is required for a wound
irrigation (lavage)
______________ which refers to the use of suction equipment to apply negative pressure to a variety of wound types
vacuum-assisted closure (VAC), wound VAC, vacuum sealing, and topical negative pressure
________ light and porous and readily molds to the body; used to retain dressings on wounds and to bandage the fingers, hands, toes, and feet; supports dressings and at the same time permits air to circulate; can be impregnated with petroleum jelly or other medications for application to wounds.
Gauze
_____________ applied to provide pressure to an area.
Elasticized bandages
__________ used to anchor bandages and to terminate them; usually are not applied directly over a wound because of the discomfort the bandage would cause
Circular turns
___________ used to bandage parts of the body that are fairly uniform in circumference
Spiral turns
____________ used to bandage cylindrical parts of the body that are not uniform in circumference
Spiral reverse
____________ used to cover distal parts of the body
Recurrent turns
___________ permit some movement after application.
Figure-eight turns
arm sling and straight abdominal are types of what?
binder
HEAT OR COLD: has been a long-standing remedy for aches and pains, and people often equate heat with comfort and relief
heat
HEAT OR COLD: causes vasodilation and increases blood flow to the affected area, bringing oxygen, nutrients, antibodies, and leukocytes
HEAT OR COLD: promotes soft tissue healing and increases suppuration
heat
HEAT OR COLD: disadvantage is that it increases capillary permeability which may result in edema or an increase in preexisting edema
heat
HEAT OR COLD: often used for clients with musculoskeletal problems
heat
- HEAT OR COLD: lowers the temperature of the skin and underlying tissues and causes vasoconstriction
cold
HEAT OR COLD: reduces the supply of oxygen and metabolites, decreases the removal of wastes, and produces skin pallor and coolness
cold
HEAT OR COLD: disadvantage is prolonged exposure results in impaired circulation, cell deprivation, and subsequent damage to the tissues from lack of oxygen and nourishment
cold
HEAT OR COLD: most often used for sports injuries to limit postinjury swelling and bleeding
cold
_________________ adapt to temperature changes. Clients may be tempted to change the temperature of a thermal application because of the change in thermal sensation following adaptation
Temperature (thermal) receptors
________________ occurs at the time the maximum therapeutic effect of the hot or cold application is achieved and the opposite effect begins
rebound phenomenon
heat produces maximum vasodilation in ______ minutes
20 to 30
cold applications, maximum vasoconstriction occurs when the involved skin reaches a temperature of ________
15°C (60°F)
________ is applied locally by means of a hot water bottle, aquathermia pad, disposable heat pack, or electric pad
Dry heat
_________ can be provided by compress, hot pack, soak, or sitz bath
Moist heat
_________ is generally applied locally by means of a cold pack, ice bag, ice glove, or ice collar
Dry cold
_________ can be provided by compress or a cooling sponge bath
Moist cold
___________ (also referred to as a K-pad) is constructed with tubes containing water
Aquathermia pad
__________ provide a constant, even heat, are lightweight, and can be molded to a body part
Electric pads
_________ is a moist gauze dressing applied to a wound or injury, and can either be hot or cold
compress
_______ refers to immersing a body part in a solution or to wrapping a part in gauze dressings and then saturating the dressing with a solution
soak
___________ is to reduce a client’s fever by promoting heat loss through conduction and vaporization
cooling sponge bath
