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Patient Care final > would care II > Flashcards

would care II Flashcards

1
Q

What phase: red, swollen, firm, warm

A

inflammatory

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2
Q

Evidence of epitheliazation

A

pale pink cells

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3
Q

Mature characteristics

A

flat, white, pale, soft

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4
Q

immature characteristics

A

raised, red, rigid

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5
Q

3 depths of a wound

A

superficial
partial thickness
full thickness

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6
Q

wound extends into epidermis, dermis or both but not subcutaneous

A

partial thickness

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7
Q

epidermis, dermis, subcutaneous

A

full thickness

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8
Q

What are the six stages of pressure injuries

A

Stage 1-4
unstageable
deep tissue pressure

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9
Q

intact skin with non-blanchable erythema

A

Stage I Non blanchable erythema of intact skin

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10
Q

partial thickness skin loss with exposed dermis, viable, pink or red, moist and may present intact or ruptured blister

A

Stage II Partial thickness skin loss with exposed dermis

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11
Q

full thickness loss of skin, fat is visible and ulcer and granulation tissue and epibole (round edges) are often present

  • undermining and tunneling may occur
  • slough and eschar
A

stage III Full thickness skin loss

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12
Q

full thickness skin and tissue loss with exposed palpable fascia, muscle, tendon ligament or cartilage in the ulcer
-rolled edges, tunneling, undermining often

A

Stage IIII Full thickness skin and tissue lost

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13
Q

when full thickness skin and tissue loss to the extent of tissue damage cannot be determined due to slough or eschar

A

unstageable pressure injury

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14
Q

non blanch able deep red, maroon, or purple revealing dark wound blood or blood filled blister

A

Deep Tissue Pressure Injury

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15
Q

if slough or eschar obscures the extent of the tissue loss this is considered what type of pressure injury?

A

unstageable

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16
Q

Characteristics of Venous Ulcer

A
  • proximal to med. malleolus
  • irregular shape
  • excessive exudation
  • pinkish-red base
  • brown purple discoloration
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17
Q

Five interventions for venous ulcers

A
  1. pliable non stretchable dressing
  2. fitted socks
  3. gentle rinsing basin
  4. intermittent compression (jobst pump)
  5. mild weight bearing exercise
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18
Q 
superior to lateral malleolus, feet, and toes
irregular shape
pale base with poor granulation
severe pain
gangrene
A

Ischemic or arterial ulcers

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19
Q

Should you elevate arterial ulcers?

A

NO

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20
Q

What are three types of burns

A

thermal

chemical electrical

21
Q

When are scalds most prevalent?

A

Children 1-5 years

22
Q

Who is at most risk for for flammable liquid burns?

A

men 17-30 years

23
Q

Three zones of tissue damage from burns?

A

Hyperemia
coagulation
stasis

24
Q

irreversible damage in a burn

A

coagulation zone

25
Q

injured, dies without intervention in burn

A

stasis

26
Q

minimal cell damage, recovers in burn

A

hyperemia zone

27
Q

Describe five depths of a burn injury?

A

Superficial ( epidermis only, sunburn, no blisters)
Superficial Partial Thickness (upper layers of dermis, intact blisters)
Deep partial Thickness ( destruction of epidermis, dermis)
Full Thickness ( ruined epidermis and dermis, no pain. may reach fat)
Subdermal ( can reach bone and muscle)

28
Q

what depth of a burn is it if destructs the epidermis and severe damage to dermis. Mixed red and white color, nerve endings can be damaged, along with hair and sweat glands

A

Deep Partial Thickness

29
Q

Complete destruction of epidermis and dermis, no pain, subcutaneous fat may have damage is what depth of burn

A

Full thickness burn

30
Q

Complete destruction of all tissue from epidermis to subcutaneous tissue including muscle and bone

A

Subdermal burn

31
Q

clear drainage

A

serous

32
Q

blood tinged drainage(vessel dialation)

A

serosanguineous

33
Q

creamy yellowish containing neutrophils, macrophils, RBC and WBC

A

Exudate

34
Q

scab

A

dessication

35
Q

yellow or yellow whitish, dried exudate

A

Slough

36
Q

white colored, healthy tissue,over hydrated

A

maceration

37
Q

undermining, crescent shaped wound

A

undermining

38
Q

tract/sinus deep wound

A

tunneling

39
Q

Describe Ankle Brachial Index

A 
measure brachial (SBP) and ankle SBP in supine and divide ankle/brachial
should be about 1.0, if less than .8 arterial insufficiency
40
Q

What are the ranges for normal, borderline perfusion, severe ischemia, and critical limb ischemia?

A

NOrmal 1.0-1.3

Severe ischemia

41
Q

Turbulane sound or wooshing

A

bruits

42
Q

Name three arterial vascular tests

A
  1. rubor of dependency
  2. venous filling time
  3. claudication time
43
Q

Describe Rubor of Dependency (arterial test)

A

patient supine
leg elevated 60 degrees for 1 min (normal has no color change, pallor presents if insufficient blood flow)
when leg is placed below heart level, color will change form pink to bright red

44
Q

What causes an abnormal reading of Rubor of Dependency (arterial)

A

due to reactive hyperemia or rubor or dependency compensating for tissue hypoxia
(if its a venous problem veins will allow the blood to back and area will change)

45
Q

Describe Venous Filling Time (arterial test)

A
  • only works in people with competent venous sytems
  • patient supine at 60 degrees for 1 min then returned
  • record filling time
  • if greater than 10-15 = arterial problems
46
Q

Describe Claudication time (arterial test)

A

treadmill walk for 1 mile until calf pain

47
Q

What are three venous tests for vasculature?

A
  1. percussion test
  2. trendelenburg’s Test (should take about 30 seconds if not, incompetent)
  3. Holms Sign (DVT test)
48
Q

What should a light touch sensation feel like

A

10g or 5.07 filament

Patient Care final (7 decks)

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