Week Two Flashcards

1
Q

What are the most common safety hazards occurring through the life cycle?

A

age and development, lifestyle, mobility and health status, sensory perceptual alterations, cognitive awareness, emotional state, ability to communicate, safety awareness, environmental factors

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2
Q

What is the purpose of the NAtional Patient Safety Goals?

A

System wide solutions. bar coding medication patient identification, number of times you ask about surgery

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3
Q

Bioterrorism

A

intentional attack using weapons of viruses, bacteria, and other germs

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4
Q

What is an adult home hazard appraisal?

A

Assessing the home for potential causes of falls, fires, poisoning, suffocation, and other accidents

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5
Q

Four specific phases of disaster planning

A

mitigation, preparedness, response, recovery

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6
Q

RACE

A

Remove clients from danger, activate fire alarm, contain the fire, extinguish the fire when confinable and evacuate the area as directed

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7
Q

Hendrich Assessment

A

get up and go test - fall assessment

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8
Q

Safety Monitoring Device

A

Leg Band Alarm, Bed Exit Monitoring Alarm. side rails do not protect all clients from falls

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9
Q

Restraints

A

protective devices used to limit the physical activity of the client or a part of the body

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10
Q

Physical Restraint

A

any manual method or physical or mechanical device, material, or equipment attached to the client’s body. They cannot be moved easily and they restrict the client’s movement

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11
Q

Chemical Restraint

A

Medication

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12
Q

Reasons for restraint use acceptable

A

to avoid and/or prevent purposeful or accidental harm to the client, to do what is required to provide medically necessary treatment that could not be provided by any other means

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13
Q

How long after applying restraints must the RN have to practitioner see the client face-to-face?

A

1 hour for evaluation

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14
Q

How long is a written restraint order valid for?

A

4 hours

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15
Q

Surgical Care- How long after applying restraints must the RN recieve the primary care’s written order?

A

12 hours

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16
Q

Surgical Care - How often must the restraint order be renewed?

A

daily

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17
Q

What do both standard of restraints require?

A

reason, time frame, type of restraint, continual monitoring, RN documentation that the need for the restraint was made clear both to client and support person, clients have a right to be free from restraints that are not medically necessary, restraints cannot be used for staff convenience or client punishment, restraints use only after every possible means of ensuring safety are unsuccessful and documented

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18
Q

Alternatives to restraints

A

buddy systems take turns staying with and observing client, place unstable client sin an area that is constantly or closely supervised, prepare clients before a move to limit relocation shock and confusion, stay with client using a bedside commode or bathroom if client is confused or sedated or has a fait disturbance or a high risk score for falling, monitor meds, lowest position beds, use 1/2-3/4 rather than full length side rails, removable lap table, wedge pillows or pads against the sides of wheelchairs, relaxation techniques, personal items, ongoing assessment

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19
Q

Jacket (vest)

A

safety of confused or sedated clients

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20
Q

Extremity Restraint

A

immobilize limb for therapeutic reasons

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21
Q

Waist/Belt Restraint

A

used when moved on stretcher or wheelchair

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22
Q

Elbow Restraints

A

used to prevent infants and small children from flexing elbow

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23
Q

Mitt Restraint

A

prevent confused client from using hands or fingers to scratch or injure themselves or pulling medical equipment out

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24
Q

Four basic elements for body alignment and mobility

A

alignment and posture, joint mobility, balance, coordinated movement

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25
Q

Alignment and Posture

A

bring body parts into position in a manner that promotes optimal balance and max body function whether the individual is standing, sitting, or lying down

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26
Q

Three important principles of alignment and posture

A

center of gravity, line of gravity, base of support

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27
Q

Center of Gravity

A

point at which all of the body’s mass is centered

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28
Q

Line of Gravity

A

imaginary line drawn through the body’s center of gravity

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29
Q

Posture

A

position of the body in relationship to the surrounding space.

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30
Q

Base of Support

A

foundation on which the body rests, the broader the base of support and the lower the center of gravity, the greater the stability and balance

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31
Q

Joint Mobility

A

functional unit of the musculoskeletal system

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32
Q

ROM

A

maximum movement that is possible for a joint

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33
Q

Pronation

A

moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body

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34
Q

Eversion

A

turning the sole of the foot outward by moving the ankle joint

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35
Q

Extension

A

increasing the angle at the joint

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36
Q

supination

A

moving the bones of the forearm so the the palm of the hand faces upward when held in front of the body

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37
Q

Internal Rotation

A

inward movement of the bone around it’s central axis

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38
Q

Abduction

A

movement of the bone away from the midline of the body

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39
Q

Adduction

A

movement of the bone toward the midline of the body

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40
Q

Flexion

A

Decreasing the angle of the joint

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41
Q

Dorsi-flexion

A

point the toes of each foot upward

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42
Q

inversion

A

turning the sole of the foot inward by moving ankle joint

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43
Q

hyperextension

A

further extension or straightening of the joint

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44
Q

plantar flexion

A

point the toes of each foot downward

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45
Q

external rotation

A

external movement of the bone around its central axis

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46
Q

Balance

A

mechanisms involved in maintaing balance and posture.

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47
Q

Balance body parts

A

labyrinth (inner ear), vision, stretch receptors of muscles and tendons

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48
Q

Proprioception

A

awareness of posture, movement, changes in equilibrium, knowledge of position, weight, resistance of objects in relation to body

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49
Q

Coordinated Movement

A

balanced, smooth, purposeful movement is the result of proper functioning of cerebral cortex, cerebellum

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50
Q

Cerebral Cortex

A

initiates voluntary motor activity

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51
Q

Cerebellum

A

coordinates the muscles involved in voluntary movement

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52
Q

Isometric Exercise

A

muscle contraction without moving the joint (no change is muscle length), exerting pressure against a solid object, mild increase in HR and cardiac output, no apparent increase in blood flow to other parts of the body, strengthening abdominals, gluteal, and quads, maintaining strength in immobilized muscles in casts or traction, endurance training

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53
Q

Isotonic Exercise

A

Muscle shortening to produce muscle contraction and active movement, HR and cardiac output increase to increase blood flow to all parts of the boy, useful for increasing muscle tone, mass, and strength, running, walking, swimming, cycling

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54
Q

Isokinetic Exercise

A

resistive exercise, an increase in BP and blood flow to muscle occurs, muscle contraction or tension against resistance, used in physical conditioning and build up certain muscle groups, lifting weights

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55
Q

Example Isokinetic

A

weight lifting

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56
Q

Example Isotonic

A

swimming, walking, running, cycling

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57
Q

Example Isometric

A

quad sets

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58
Q

Aerobic Exercise

A

activity during which the amount of oxygen taken in the body is greater than that used to perform the activity. use large muscle groups that move repetitively, improve cardiovascular conditioning and physical fitness

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59
Q

Anaerobic Exercise

A

involved activity in which muscles cannot draw out enough oxygen from the blood stream and anaerobic pathways are used to provide additional energy for a short time. endurance training, weight lifting, sprinting

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60
Q

Preambulatory exercises

A

strengthen muscles for walking for clients who have been immobilized for a prolonged period. Quad drills or sets

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61
Q

Passive ROM

A

another person moves each of a client’s joints through complete range of movement as ordered while awake to maintain joint flexibility

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62
Q

Active ROM

A

isotonic exercises in which the client moves each joint in the body through its complete range of motion to maintain or increase muscle strength and endurance, help to maintain cardiorespiratory function in immobilized client, prevent deterioration at joint capsules and contractures

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63
Q

Active Assistive ROM

A

client uses stronger opposite arm or leg to move each joint of a limb incapable of active motion and continues movement passively to its max degree to learn to support and move the weak arm or leg and increase active movement on the strong side and maintain joint flexibility on the weak side

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64
Q

stance phase

A

hell of one foot strikes the ground, body weight is spread over that foot while the other heel pushes off and leaves the ground

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65
Q

swing phase

A

leg from behind moves in front of the body

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66
Q

friction

A

a force acting parallel to the skin surface

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67
Q

how much are we allowed to lift

A

35 pounds

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68
Q

bad things body mechanics

A

twisting, stooping

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69
Q

Purpose of transfer gait belt

A

safety device used for moving of transferring a client

70
Q

Hydraulic lift device

A

used for clients who cannot help themselves or who are too heavy for others to lift

71
Q

Lateral Assist Device

A

reduce client surface friction during side to side transfers. roller boards, slide boards, transfer boards

72
Q

Supine Position

A

back lying position

73
Q

Supine and dorsal recumbent positions purpose

A

provide comfort and facilitate healing following certain surgeries or anesthetics

74
Q

dorsal recumbent position

A

back lying with head and shoulders slightly elevated on a small pillow

75
Q

Prone position

A

lies on abdomen with head turned to one side

76
Q

prone purpose

A

to prevent hip and knee flexion contractures, promotes drainage from the mouth and useful for unconscious clients or clients recovering from surgery of mouth or throat

77
Q

Lateral/Side Lying

A

lies on one side of body

78
Q

lateral side lying purpose

A

used for resting and sleeping clients, relieves pressure on scrum and heels in individuals who sit for much of the day or who are confined to bed

79
Q

Sim’s (semi-prone)

A

assumes posture halfway between lateral and prone position

80
Q

sim’s purpose

A

facilitate drainage from mouth, prevent aspiration of fluids

81
Q

Paraplegia

A

paralysis of the legs

82
Q

quadriplegia

A

paralysis or the legs, arm, trunk, of the body below the level of associated injury to the spinal cord

83
Q

Semi-Fowler’s

A

15-45 degree with or without knee flexion

84
Q

Fowler’s

A

45-60 degrees with or without knee flexion

85
Q

High Fowler’s

A

60-90 degrees with or without knee flexion

86
Q

Fowlers’ positions purpose

A

difficult breathing and some people with heart problems

87
Q

Pressure ulcer

A

injury to the skin and/or underlying tissue usually over a bony prominence as a result of force alone or in combination with movement

88
Q

Pressure Area

A

compressing downward force on a body area

89
Q

Ischemia

A

a deficiency in the blood supply to the tissue

90
Q

Reactive Hyperemia

A

bright red flush of skin

91
Q

Vasodilation

A

extra blood floods to the area to compensate for the preceding period of impeded blood flow

92
Q

Pressure Duration

A

low pressure over a prolonged period causes tissue damage, as well as high intensity pressure over a short period of time

93
Q

Tissue Tolerance

A

ability of the tissue to endure pressure depends upon the integrity of the tissue and the supporting structures

94
Q

Risk factors that contribute to the formation of pressure ulcers?

A

friction, shearing force, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, chronic medical condition, other factors

95
Q

Shearing Force

A

a combination of friction and pressure that occurs when a client assumes a sitting position in bed because the body tends to slide downward toward the foot of the bed because the deeper tissues and the superficial tissues meet which causes damage to the blood vessels and tissues in the area

96
Q

Nutrition for pressure ulcers

A

2,500 mL fluid daily, high protein, A C B1 B5 zinc

97
Q

Braden Scale for predicting pressure sore risk

A

sensory perception, moisture, activity, mobility, nutrition, friction and shear

98
Q

braden scale scoring

A

lower the number, higher the risk

99
Q

norton’s pressure area risk

A

general physical condition, mental status, activity, mobility, incontinence

100
Q

Pressure Ulcer definition

A

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 and/or friction

101
Q

Suspected Deep Tissue Injury

A

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. the area may be preceded by tissue that is painful firm mushy body warmer or cooler as compared to adjacent tissues

102
Q

Stage 1 Pressure Ulcer

A

intact skin with non-blanchable redness of localized area usually over a bony prominence. darkly pigmented skin may not have visible blanching, its color may differ from the surrounding area. may be painful, firm, soft, warmer or cooler. may be difficult in niggers

103
Q

Stage 2 Pressure Ulcer

A

partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough may also present as an intact or open/ruptured serum-filled blister. shiny or dry shallow ulcer without slough or bruising

104
Q

Stage 3 Pressure Ulcer

A

full thickness tissue loss. subcut fat may be visible but bone tendon or muscle are not exposed. slough may be present but does not obscure the depth of tissue loss. may have tunneling

105
Q

Stage 4 Pressure Ulcer

A

full thickness tissue loss with exposed bone tendon or muscle. slough or eschar may be present on some parts of the wound bed often includes undermining or tunneling

106
Q

Unstageable Pressure Ulcer

A

full thickness tissue loss in which the base of the ulcer is covered by slough and or eschar in the wound bed

107
Q

What must be documented for pressure ulcers?

A

location, size, presence of undermining or tunneling, stage of the ulcer, color of the wound bed, condition of the wound, condition of exudates

108
Q

Serous

A

serum, clear, watery

109
Q

Sanguineous

A

hemmorhagic, large amounts of red blood cells, seen in open wounds

110
Q

Serosanguineous

A

clear and blood tinged drainage

111
Q

purulent

A

thicker, pus, blue, green, yellow

112
Q

Diagnosis Impaired Skin Integrity

A

stage one or stage two pressure ulcers, applies to pressure ulcers and wound extending through the epidermis but not through the dermis

113
Q

Diagnosis impaired tissue integrity

A

stage three or four pressure ulcers and suspected deep tissue injury, applies to pressure ulcers and to wounds extending in subcut tissue muscle or bone

114
Q

Trapeze

A

Triangular metal apparatus above a bed to assist in moving and turning clients, patient can grasp the bar with one or both hands and then raise the trunk from the bed when moving the client, makes moving and turning easier

115
Q

Overbed cradle

A

metal frame that supports the bed linens away from the patient while providing privacy and warmth

116
Q

Egg Crate Mattress

A

provides comfort and helps to distribute body weight evenly, pressure reduction for high risk clients, reduces pressure on bony prominences

117
Q

Water Bed

A

filled with water, controls temp of water to prevent or treat pressure ulcers, high risk client, stage one or two pressure ulcer, prevents or treats ulcers by equalizing pt weight against the support

118
Q

air fluidized static high air loss bed

A

forced temp controlled air circulated around millions of tiny silicone coated beads producing a fluid like movement, uniform support to body contours, decreases skin maceration by its drying effect

119
Q

static low airloss bed

A

air filled cushions divided into four or five sections, separate control permits each section to be inflated to a diff level, prevention of skin breakdown in clients who cannot turn themselves or have existing skin breakdown

120
Q

alternating pressure mattress

A

composed of a number of cells in which the pressure alternately increases and decreases, uses a pump, pressure can be reduced over bony prominences

121
Q

gel floatation pads

A

filled with a gelatinous substance similar to fat to distribute weight over entire flotation pad, when sitting the weight is distributed evenly

122
Q

Sheepskins

A

natural and artificial pads that limit pressure to affected areas, limit pressure on area of skin when the client is in bed

123
Q

Yellow wound

A

cleanse

124
Q

Red Wound

A

protect

125
Q

Black Wound

A

debride

126
Q

Granulation Phase

A

tissue needs to be protected to avoid disturbance of regeneration tissue

127
Q

Debridement

A

removal of nonviable tissue (necrotic tissue) from a wound

128
Q

Why do you debride a wound?

A

remove: tissue contaminated by bacteria and foreign bodies thereby preventing the client from invasion of bacteria, devitalized tissue or burn eschar in preparation for grafting and wound healing

129
Q

Sharp Debridement

A

scalpel or scissors is used to separate and remove dead tissue, contraindicated for bleeding disorders

130
Q

Mechanical Debridement

A

moist to moist dressings or scrubbing force of moist dressings, wide mesh gauze most common, saline, whirlpool

131
Q

Chemical Debridement

A

more selective, collagenase enzyme agents are more recommended for this use

132
Q

Autolytic Debridement

A

contain wound moisture such as hydrocolloid and clear absorbent acrylic dressings, trap the wound drainage against the eschar, body’s own enzymes in the drainage break down the necrotic tissue, takes longest but is the most selective causing the least damage to healthy and healing tissue, dressings should be changed as soon as they begin to leak or strike through

133
Q

Exudate Absorbers

A

non-adherent, dressing of powder, beads, granules, ropes, sheets, paste, that conform to the wound surface and absorb exudate, to provide a moist wound surface by interacting with exudate, facilitates debridement and rehydrates dead tissue, provides cool moist wound surface by interacting with exudate by assisting in the removal of slough

134
Q

Gauzes

A

cover surgical incisions, absorbs exudate, wet-to-dry debrides the wound, protect from trauma and infection, wound is debrided when the dressing is removed

135
Q

Hydrocolloids

A

moist, healing environment that allows clean wounds to granulate and in necrotic wounds it facilitates autolytic debridement, waterproof adhesive wafers, pastes, powders

136
Q

Hydrogels

A

facilitate autolytic debridement, add moisture to wounds, used for pressure ulders, skin tears, partial thickness wound, glycerin or water based nonadhesive jellylike sheets, granules, or gels that are oxygen permeable, unless covered by a plastic film, require secondary occulsive dressing

137
Q

Impregnated nonadherent dressings

A

woven or nonwoven cotton or synthetic materials impregnated with petrolatum, saline, zinc-saline, antimicrobials, require secondary dressings to secure in place, to cover, soothe, protect partial and full thickness wounds without exudate, provide wound protection and retain moisture of wound, used postop dressing over staple or sutures and superficial burns

138
Q

Polyurethane foams

A

nonadherent hydrocolloid dressings, need to have their edges taped down or sealed, light to highly exudating wounds, pressure ulcers, skin tears, venous stasis ulcers, surgical wounds, chemical debridement

139
Q

Transparent adhesive films

A

adhesive, plastic, semipermeable, nonabsorbent dressings allow exchange of oxygen, impermeable to bacteria and water, used for iv dressing, central line dressing, superficial wounds and pressure ulcers stage 1

140
Q

Factors to consider when securing a dressing

A

location, size, type of wound, amount of exudates, whether the wound requires debridement or is infected, freq of dressing change, ease of difficulty of dressing application and cost

141
Q

Hydrogen peroxide

A

soften and remove crusted exudate and debris

142
Q

Normal Saline

A

irrigation of clean or noninfected wounds, safest and most appropriate solution for open wounds

143
Q

Povidone idodine (betadine)

A

broad spectrum effectiveness against bacteria, spores, fungi, viruses when used on intact skin or small clean wounds

144
Q

Lactated Ringer’s

A

irrigation of clean or noninfected wounds

145
Q

Water

A

cleansing of clean or noninfected wounds

146
Q

What stage ulcers are considered partial thickness

A

stage 2

147
Q

what stage ulcers are considered full thickness

A

stage three and stage four

148
Q

Circular Technique

A

anchor bandages or terminate bandage, cover small area finger or toe

149
Q

Spiral Technique

A

bandage parts of the body that are fairly uniform in circumference such as upper arm or leg

150
Q

Recurrent Technique

A

cover distal parts of the body, such as the end of a finger, the skull, or the stump of an amputation

151
Q

Figure of Eight Technique

A

bandage elbow, knee, or ankle because they permit some movement after application

152
Q

How should you bandage?

A

distal to proximal

153
Q

Alopecia

A

loss of hair

154
Q

callus

A

thickened skin on your hands or the soles of your feet

155
Q

corn

A

thickened skin on the top or side of a toe, usually from shoes that do not fit properly

156
Q

cyanosis

A

blue color to the skin, lack of oxygen

157
Q

diaphoresis

A

profuse sweating

158
Q

ecchymosis

A

bruising, purple, ruptured blood vessels

159
Q

edema

A

swelling

160
Q

erythema

A

redness or rash

161
Q

excoriation

A

an injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn

162
Q

gingivitis

A

Inflammation of the gums, characterized by redness and swelling.

163
Q

halitosis

A

bad breath

164
Q

hirsutism

A

abnormal hair growth, excessive hair growth

165
Q

jaundice

A

yellowing of skin, sclera,

166
Q

pallor

A

pale color

167
Q

pediculosis

A

infestation with lice

168
Q

petchia

A

small purplish spot on a body surface, such as the skin or a mucous membrane, caused by a minute hemorrhage and often seen in typhus.

169
Q

pruritus

A

itching

170
Q

tartar

A

A hard, yellowish deposit on the teeth, consisting of organic secretions and food particles deposited in various salts, such as calcium carbonate.

171
Q

plaque

A

a soft thin film of food debris, mucin, and dead epithelial cells on the teeth, providing the medium for bacterial growth. It contains calcium, phosphorus, and other salts, polysaccharides, proteins, carbohydrates, and lipids, and plays a role in the development of caries, dental calculus, and periodontal and gingival diseases.