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21 Cards in this Set
- Front
- Back
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What are the phases of Wound Healing?
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1. Hemostasis - blood arrest
2. Inflammation - Attack of leukocytes 3. Proliferation - formation of granulation tissue 4. Maturation/Remodeling - remodel collagen to look like surrounding tissue |
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How long does each phase of wound healing last?
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1. Hemostasis - immediately
2. inflammation - follows hemostasis, lasts 4-6 days 3. Proliferation - several weeks (depending on severity) 4. Maturation/remodeling - starts 3 weeks from injury, may last months or years depending on severity |
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Describe the first phase of wound healing
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Hemostasis - bleeding hampered by vessel constriction and blood clot formation. Same vessels dilate for inc blood flow.
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Describe second phase of wound healing.
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Inflammation - inc blood flow, inc permeability allows diapedesis of leukocytes for cleanup. 24hrs later, macrophages clear debris, and trigger proliferation of granulation tissue.
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Describe third phase of wound healing?
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Proliferative - formation of granulation tissue = collagen deposits, capillary formation, fibrin formation across chasm, thin epithilial layer covering
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Describe 4th phase of wound healing
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Maturation/remodeling = collagen that was haphazardly thrown into wound is remodeled to look more similar to surrounding tissue. may take months or years.
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Who is at risk for pressure ulcer development?
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- malnourished, dehydrated
- macerated e.g. incontinent - elderly - immobile - neuromuscular disorders, spinal cord injuries, paralyzed, emo ppl, sedatives, unconscious - altered mental state - depreciated self care |
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define ischemia
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local anemia
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what is term for removing necrotic tissue?
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debridement
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What is the first indication that a pressure ulcer may be developing?
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blanching (ischemia) - followed by hyperemia - but should fade within about 1.5 hrs
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Differentiate the different pressure ulcer stages.
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Stage 1 - nonblanchable erythtema
Stage 2 - necrosis down to dermis = partial thickness skin loss Stage 3 - down to subcutaneous tissue = full thickness skin loss Stage 4 - down to mucles, bones, tendons |
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You see a dry, leathery black crust on a pressure ulcer. What is it? What should be done to it?
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Eschar - necrotic tissue. Debridement necessary.
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What would happen if there is a decrease in surfactant?
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surfactant reduces surface tension in alveoli
decrease in surfactant => alveoli collapse |
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How many lobes in each lung?
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Right lung has three lobes (shorter, wider due to liver)
Left lung has 2 lobes (longer, thinner, cardiac notch) |
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lung collapse (alveolar collapse) is known as?
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atelectasis
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How is respiratory functioning different in older adults?
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- Tissues are less elastic, more rigid
- decreased strength in diaphragm and other ventilation muscles - kyphosis, prominent bony landmarks - barrel chest indicative of COPD |
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vibrations over lungs called
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fremitus
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how do you assess chest expansion? aka?
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aka respiratory excursion.
place hands on both sides of chest - check for symmetry |
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what sounds do you hear when percussing chest wall?
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resonance - lungs, low pitch
hyperesonance - emphysema lungs flat - bone/muscle dull - liver, medium pitch tympany - stomach, high pitch |
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What sounds should you hear when auscultating the lungs?
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vesicular - low pitch over lungs
bronchial - high pitch over trachea bronchiovesicular - medium pitch over main bronchi |
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abnormal lung sounds aka? eg.?
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aka adventitious
crackles - discontinuous, contains fluid wheezes - continuous, swelling |
