Caring/spirituality/wound Care

Front 1

the major outcome of nursing care is rehabilitation and feelings of self-actualization by the patient

Back 1

Lydia E. Hall

Front 2

caring is the central theme of nursing care, nursing knowledge, and nursing practice

Back 2

Madeline Lieninger

Front 3

nursing is concerned with promoting and restoring health, preventing illness, and caring for the sick; caring is important in all nursing roles

Back 3

Jean Watson

Front 4

striving to understand an event as it has meaning in the life of another

Back 4

Knowing

Front 5

being emotionally present for another

Back 5

Being With

Front 6

doing for the other person as he or she would do for himself if possible (still allowing pt. to maintain sense of self)

Back 6

Doing For

Front 7

facilitating the other's passage through life's transitions and unfamiliar events

Back 7

Enabling

Front 8

Where is the destruction occuring in centriacinar emphysema?

Back 8

distal terminal bronchioles and upper lobe Resoiratory Bronchioles

(most common type in smokers)

Front 9

5 principles of Caring

Back 9

Knowing
Being With
Doing For
Enabling
Maintaining Belief

Front 10

3 spitiruallity needs

Back 10

-meaning and purpose
-love and relatedness
-forgiveness

Front 11

3 phases of the helping relationship

Back 11

Orientation
Working
Termination

Front 12

restating another's message more breifly using your own words

Back 12

paraphrasing

Front 13

checking the understanding of an unclear message

Back 13

clarifying

Front 14

centering in on key elements

Back 14

focusing

Front 15

concise review of key aspects of interaction

Back 15

summary
(summarizing)

Front 16

revealing personal experiences, thoughts, or ideas (when appropriate)

Back 16

self-disclosing

Front 17

nurse makes sure she heard the pt. correctly

Back 17

validation

Front 18

4 components of the assertive response

Back 18

1) having empathy
2) desribing one's feelings or situation
3) clarifying one's expectations
4) anticipating consequences

Front 19

all or portion of dermis is still intact

Back 19

partial thickness wound

Front 20

entire dermis, sweat glands, hair follicles are severed

Back 20

full thickness wound

Front 21

dermis and underlying sub q fat tissue are damaged or destroyed

Back 21

complex wound

Front 22

partial or total seperation of wound layers as a result of excessive stress or wounds that do not heal

Back 22

dehiscencce

Front 23

wound completely seperates w/ protrousion of viscera thru the surgical area - most serious complication of dehiscence

Back 23

evisceration

Front 24

wound edges well-approximated, minimal tissue loss

Back 24

primary intention

Front 25

wound edges not well-aproximated, requires more tissue replacement, often contaminated (infected)

Back 25

secondary intention

Front 26

wound left open for several days to allow edema or infection to resolve, then closed

Back 26

tertiary intention

Front 27

acid mantle of normal skin

Back 27

pH 4.5-5.5

Front 28

normal albumin

Back 28

3.5g/dL or greater
less than 2.8 g/dL is severe depletion

Front 29

normal transferrin

Back 29

200mg/dL or greater
less than 160mg/dL is severe depletion

Front 30

normal prealbumin

Back 30

14 mg/dL or greater
less than 11 mg/dL is severe depletion

Front 31

RYB wound classification

Back 31

R= red (protect)
Y= yellow (cleanse)
B= black (debride)

Front 32

documentation of pressure ulcer

Back 32

LxWxD in centimeters
stage
take picture
draw shape
describe

Front 33

systemic inflamation response to infection - s/s include fever, tachycardia

Back 33

Sepsis
50% of pts. with sepsis die

Front 34

____ _____ is a safe and appropriate method for cleansing most ulcers

Back 34

saline irrigation

Front 35

nutrients essential for wound healing

Back 35

carbs
fats
proteins
vitamins A, C, E, K, zinc
fluids

Front 36

occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins - lasts minutes

Back 36

hemostasis phase

Front 37

lasting about 4 to 6 days, white blood cells, predominantly leukocytes and macrophages, move to the wound. patient has a generalized body response, including a mildly elevated temperature

Back 37

inflamatory stage

Front 38

also known as the fibroblastic, regenerative, or connective tissue phase, new tissue is built to fill the wound space - lasts weeks

Back 38

proliferation stage

Front 39

possibly continuing for months or years. Collagen that was haphazardly deposited in the wound makes healed wound stronger and more like adjacent tissue.

Back 39

remodeling stage

Front 40

providing a _____ environment will heal wounds 3x's faster

Back 40

moist

Front 41

2 types of hydrocolloid dressings

Back 41

duoderm
tegasorb

Front 42

hydrocolloid dressings are NOT appropriate for...

Back 42

infected wound
heavily exudating wound
also, may macerate skin

Front 43

2 types of hydrogel dressings

Back 43

vigilon
aquasorb

Front 44

use hydrocolloid dressings for... (3 things)

Back 44

Shallow to moderate-depth skin ulcers
Wounds with (moderate) drainage
In conjunction with packing for open, deep wounds

Front 45

use hydrogel dressings on ....

Back 45

Partial- and full-thickness wounds
Necrotic wounds
Burns
should be changed every 24-72 hrs.

Front 46

primary dressing of choice for partial thickness wounds

Back 46

hydrogel

Front 47

2 types of alginate dressing

Back 47

sorban
algiderm

Front 48

dressing of choice for deep wounds

Back 48

alginate

Front 49

deep, cave-like wound characteristic

Back 49

sinus tract

Front 50

wound is larger than the opening

Back 50

undermining

Front 51

Cutting or sharp instrument; wound edges in close approximation and aligned

Back 51

inscision

Front 52

Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma

Back 52

contusion

Front 53

Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded

Back 53

abrasion

Front 54

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue

Back 54

laceration

Front 55

Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental

Back 55

puncture

Front 56

Foreign object entering the skin or mucous membrane and lodges in underlying tissue; fragments possibly scattering throughout tissues

Back 56

penetrating

Front 57

Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Back 57

avulsion

Front 58

Secretion of exotoxins or release of endotoxins by living organisms

Back 58

microbial

Front 59

Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

Back 59

chemical

Front 60

ingēns, ingentem

Back 60

huge

Front 61

Ultraviolet light or radiation exposure

Back 61

irradiation

Front 62

wound persists for 2 weeks or longer, does not follow normal healing process

Back 62

chronic wound

Front 63

The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

Back 63

stage 1 pressure ulcer

Front 64

Partial-thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater

Back 64

stage 2 pressure ulcer

Front 65

Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue

Back 65

stage 3 pressure ulcer

Front 66

Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (eg, tendon or joint capsule). Sinus tracts may also be associated.

Back 66

stage 4 pressure ulcer

Front 67

pressure ulcers are staged by ____.

Back 67

depth

Front 68

contamination vs. infection

Back 68

pathogens are introduced
pathogens invade tissues