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42 Cards in this Set
- Front
- Back
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TYPES OF NONSPECIFIC BODY DEFENSES |
#1 SKIN, HAIR, NAILS, MUCUS MEMBRANES |
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Approximated |
Closed. |
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Compress |
A moist gauze dressing applied to a wound. |
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Debridement
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Removal of the necrotic material. |
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Dehiscence
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Partial or total rupturing of a sutured wound.
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Eschar
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A wound covering of dried plasma proteins and dead cells that occurs if the wound does not close by epithelialization.
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Evisceration
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Protrusions of the internal viscera through an incision.
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Excoriation
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Area of loss of the superficial layers of the skin.
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Exudate
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Material that has escaped from blood vessels during the inflammatory process and is deposited in the tissue or on tissue surfaces.
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Fibrin
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Connective tissue.
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Friction
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A force acting parallel to the skin surface. *Use trapeze to move client to prevent* |
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Granulation tissue
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The initial translucent, fragile tissue that forms during the proliferative phase of wound healing.
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Hematoma
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A localized collection of blood underneath the skin that may appear as reddish-blue swelling.
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Hemorrhage
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Massive bleeding.
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Hemostasis
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Cessation of bleeding. |
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Ischemia |
Deficiency in the blood supply to the tissue and cells are deprived of oxygen.
PRESSURE CAUSES ISCHEMIA - Turning skin pale=lack of blood |
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Keloid
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Hypertrophic scar.
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Maceration
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Tissue softened by prolonged wetting or soaking.
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Packing
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Gauze used to absorb exudate in a wound dressing.
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Phagocytosis
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The process during which macrophages engulf cellular debris and microorganisms.
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Pressure
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Compression of tissue.
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Pressure ulcers
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Result of localized tissue ischemia caused by unrelieved pressure.
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Primary intention healing
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Occurs where the tissue surfaces have been approximated, and there is minimal or no tissue loss.
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Purulent exudate
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Thicker, yellow-, blue-, or green-tinged exudate.
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Pus
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Consists of leukocytes, liquefied dead tissue debris, dead and living bacteria.
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Reactive hyperemia
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Red flush of skin that occurs when pressure is relieved from an area.
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Sauguinous exuate
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Bloody.
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Secondary intention healing
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Occurs in a wound that is extensive, and the edges cannot be approximated.
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Serosanguinous
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Mixed drainage consisting of clear and blood-tinged material.
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Serous exudate
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clear, watery drainage.
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Shearing force
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Combination of friction and pressure. *Use trapeze to move client to prevent* |
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Sitz bath
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Used to soak a client's perineal or rectal area.
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Suppuration
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The process of pus formation.
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Tertiary intention
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Wounds left open for 3-5 days, then surgically closed.
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Vasoconstriction
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Decreased blood flow to an area can be caused by decreased temperature of tissue.
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Vasolidation
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The process in which extra blood flows to the area.
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FUNCTIONS OF THE SKIN |
#1 PROTECTION -PREVENT PENETRATION -PERCEPTION -TEMP REGULATION -IDENTIFICATION -VITAMIN D PRODUCTION -ABSORPTION AND EXCRETION -WOUND REPAIR |
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WOUND TYPES |
CLEAN OPEN/CLOSED CLEAN-CONTAMINATED CONTAMINATED DIRTY - EX: GRASS/GLASS
INTENTIONAL - EX: SURGERY UNINTENTIONAL
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WOUND CLASSIFICATION |
PARTIAL THICKNESS- SCRAPE FULL THICKNESS - GOES THROUGH MUSCLE |
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WOUND TYPES |
INCISION- SCALPEL CONTUSION - INTERNAL WOULD / BRUISE ABRASION - SCRAPE/ROAD RASH PUNCTURE LACERATION- CUT WITH GLASS PENETRATING WOUND- BULLET/FISH HOOK
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REACTIVE HYPEREMIA |
ONCE PRESSURE IS RELIEVED - REDNESS SHOULD DISAPEER WITH IN 1/2 THE AMOUNT OF TIME THE REDNESS WAS THERE. REDNESS WAS THERE FOR 60 MIN THEN IT SHOULD DISAPEER W/ IN 30 MIN |
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PRESSURE ULCER FORMATION SITES |
BONEY PROMINANCES: * Buttocks* Elbow * Hips * Heels * Ankles * Shoulders / Back * Back of head |
