Nur 115 Test #4 Stack D

Front 1

What are the two different types of ulcers?

Back 1

pressure ulcers

venous leg ulcers (stasis)

Front 2

What is the patho of venous leg ulcers?

How does this differ than the path of pressure ulcers?

Back 2

internal pressure from blood stasis

pressure ulcers have external pressure

Front 3

What is the definition of venous leg ulcers?

Back 3

inflammation of legs with edema and pigmentation resulting in necrotic crater like lesions of the skin, caused by poor venous return secondary to incompetent valves of deep veins

Front 4

Fluid and edema compress ___________ and ________ and create an environment for a venous leg ulcer to develop.

Back 4

arteries and veins

Front 5

What is the definition of a pressure ulcer?

Back 5

a specific tissue injury caused by unrelieved pressure that results in damage to underlying tissue.

Front 6

What are the risk factors for pressure ulcers?

Back 6

immobility
malnutrition
incontinence
impaired mental status
diminished sensation
elevated body temp
localized edema
chronic illness

Front 7

Braden assessment tool uses risk factors, when the score is low on the tool, what does that mean?

Back 7

the risk is HIGH

Front 8

Shearing force causes damage to what part of the skin?

Back 8

deep in the tissues, causing undermining at the presure point....
underlying tissue capillaries are stretched and angulated by the shear force

Front 9

Friction force causes damage to what part of the skin?

Back 9

epidermis or top layer of the skin...skin appears red and painful and can be called sheet burn.

Front 10

Staging should only be used with pressure ulcers over....

Back 10

bony prominences

Front 11

Staging of pressure ulcers should focus on the _______ of the ulcer at the time of assessment.

Back 11

depth

Front 12

Stage I is basically redened skin that does not______________.

Back 12

blanch. Red that you can't make white. Nonreactive hyperemia

Front 13

What is different about stage 1 than any other stage?

Back 13

it is the only stage that the problem is totally reversible.

Front 14

What part of the skin is involved in Stage 1?

Back 14

epidermis

Front 15

What part of the skin is involved in stage 2 PU?

Back 15

epidermis and dermis

Front 16

Describe what a stage 2 PU can be?

Back 16

blister
abrasion
shallow crater
swollen
painful

Front 17

What part of skin is involved in stage 3 PU?

Back 17

full thickness of the skin, including sub cut tissue. may include fascia

Front 18

If there is no sub cut tissue, then what will happen to the staging of an ulcer?

Back 18

it can go right from stage one to stage 3 or four. skipping in between

Front 19

How big does an ulcer have to be in stage 3?

Back 19

it can be as small as a pin hole...1/2 size of IV

Front 20

What is the look of a stage 4 PU?

Back 20

extensive, including tendons, muscles and bones. Can appear small on surface, but have large sinus tracts underneath.

Front 21

Wound that does not have a break in the skin. Give an example of one.

Back 21

closed wound.

being struck by blunt object, straining, twisting or deceleration force against body....

Front 22

Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity.

Back 22

acute wound. trauma from a sharp object.

Front 23

Example of a chronic wound

Back 23

pressure ulcers,

Front 24

Intentional wound example

Back 24

surgical incision, needle stick

Front 25

Superficial wound only involves this part of the skin.

Back 25

epidermal layer

Front 26

Perforating wound is a wound in which a foreign object enters and ........

Back 26

exits an internal organ

Front 27

Clean wound description

Back 27

wound containing no pathogenic organism. Example is closed surgical wound not entering GI, respiratory, genital or uninfected UI tract or oropharyngeal cavity

Front 28

Clean-contaminated wound

Back 28

Wound made under aseptic conditions, but involving body cavity that normally harbors microorganisms: GI, respt, urinary, oropharyngeal, genital

Front 29

Contaminated wound

Back 29

wound existing under conditions in which presence of mo is likely.

Front 30

Colonized wound

Back 30

one step further than Infected Wound....chronic wound

Front 31

Laceration -


Abrasion -


Contusion -

Back 31

laceration (tearing of tissues with irregular wound edges)

abrasion (superficial wound involving scraping or rubbing of skin's surface)

contusion (closed wound caused by a blow to body or blunt object)

Front 32

What are the three stages of primary intention?

Back 32

inflammatory stage (up to 3 days)

proliferative phase (3-24 days)

maturation phase (month to years)

Front 33

What is tertiary intention?

Back 33

surgery & secondary intention

Front 34

Wound edges are approximated.....what does it mean?

Back 34

they are touching, closed

Front 35

Partial thickness wound heals by....

Full thickness wound heals by....

Back 35

partial heals by regenration b/c it is only top layer

full thckns heals by scar tissue b/c it is deeper and can not regenrate

Front 36

What does the leukocyte count have to get to for a patient to be nutritionally at risk?

Back 36

1800 WBC count

Front 37

What is normal range of serum albumin?

Back 37

3.5-5.0 shows nutritional status. Low is bad

serum album also gives index on ability to heal

Front 38

What does obesity have to do with wound healing?

Back 38

the more subcutaneous tissue that they have,

Front 39

Smoking affects wound healing because.....

Back 39

it lowers hemoglobin ability to carry o2 and b/c of vasoconstriction

Front 40

A wound can't heal if it is.....

Back 40

bleeding.

Front 41

What is the main purpose of the inflammatory phase?

Back 41

vessels constrict, platelets gather to stop bleeding. clots form a fibrin matrix, histamine results in vasodilation of surrounding capilarries and exudate and wbc into damaged tissues.


Basically: controls bleeding and establishes a clean wound bed

Front 42

What are some wound characteristics during the inflammatory phase of wound healing?

Back 42

localized edema, redness, warmth and throbbing. There is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a closed compartment.

Front 43

What is the main purpose of the proliferative phase?

Back 43

filling the wound with granulation tissue, contraction of wound (and collagen added) and resurfacing of the wound by epithelialization

Front 44

Serous drainage is...

Back 44

clear, watery plasma

Front 45

Purulent drainage is....

Back 45

thick, yellow, green tan or brown.

Front 46

Serosanguineous drainage is....

Back 46

pink, pale, red, watery, mixture of clear and red

Front 47

Sanguineous drainage is.....

Back 47

bright red, indicating active bleeding

Front 48

If a wound is red, what should you do?

Back 48

protect it. usually in the late regenration phase. Keep it clean and dry.

Front 49

If a wound is yellow, what should you do?

Back 49

cleanse it. Usually contains liquid or slough and purulent drainage

Front 50

If a wound is black, what should you do?

Back 50

debride.

Front 51

What are the six categories for the Braden Pressure Ulcer Risk Assessment?

Back 51

sensory perception

moisture

activity

mobility

nutrition

friction and sheer

Front 52

The primary concern of a puncture wound is....

Back 52

internal bleeding and infection

Front 53

What is tx for stage 1 PU?

Back 53

frequent turning to relieve pressure

use pressure relieving devices

keep client clean, dry and well nourished

Front 54

What type of drsg is used for stage 1 PU?

Back 54

Tegaderm

Front 55

What is tx for stage 2 PU?

Back 55

maintain moist environment

use saline or occlusive dressing that promotes natural healing

Front 56

What is tx for stage 3 PU?

Back 56

debride by using wet to dry dressing, surgical intervention or proteolytic enzymes

Front 57

What is tx for stage 4 PU?

Back 57

cover with non-adherent dressing and change q 8-12 hrs. may require skin grafts

Front 58

What is main purpose of Tegadern film dressing on stage 1 PU?

Back 58

protects (from friction and decreases surface injury)

Front 59

What is main purpose of the other dressings for stage 2-4 PU?

Back 59

maintain it moist & protects, absorbs excessive moisture, wicks drainage away, etc

Front 60

How soon should redness be gone from an area of pressure once the pressure is removed?

Back 60

1 hour and 40 minutes....if it is not, then you can not use a turn schedule of q2h

Front 61

Why do you need the following for wound healing?

calories

protein

vit c

vit a


vit e


zinc


fluid

Back 61

calories - cell energy

protein - neogenesis, collagen, wound remodeling

vitamin c - collage, capillary health, fibroblasts

vitamin a - epithelization, wound closure


vitamin e - no known role


zinc - collage and protein


fluid - essential fluid environment for all cell function

Front 62

These three lab values signal a clinically significant malnutrition.

Back 62

serum albumin <3.5
lymphocyte count less than 1800
body weight decreased more than 15%

Front 63

How long can hydrocolloid (Duoderm) dressings stay in place?

Back 63

3-7 days, no need to cover, water resistant

Front 64

When do you NOT use hydrocolloid (Duoderm) dressing?

Back 64

when the wound is infected

with a fistula

when a wound has a deep tract

Front 65

Which type of dressing do you use for a wound with minimal exudate?

Back 65

Tegaderm

Front 66

Why do you use normal saline to clean a wound?

Back 66

because it doesn't kill the good guys

Front 67

What does heat do to the wound/injury?

Back 67

causes vasodilation and increases blood flow. Limit to 20-30 or you will have reflex vasoconstriction

Front 68

List the actions of cold therapy.

Back 68

vasoconstriction

local anesthesia

reduced cell metabolism

increased blood viscosity

decreased muscle tension

Front 69

List the actions of heat therapy.

Back 69

vasodilation

reduced blood viscosity

reduced muscle tension

increased tissue metabolism

increased capillary permeability

Front 70

If a patient is at high risk for skin breakdown, what might be used prophylactically?

Back 70

benadryl

Front 71

List in order of frequency, the most common sites of infection.

Back 71

urinary tract

wound

respiratory

blood stream

Front 72

What are the three stages of illness?

Back 72

prodromal phase

full illness phase

convalescent phase

Front 73

In what stage do specific symptoms occur?

Back 73

full illness phase

Front 74

What is core temperature?

Give example locations

Back 74

temperature of the body's deep tissues

rectum
tympanic membrane
esophagus
pulmonary artery
urinary bladder

Front 75

What is surface temperature?

Give example locations

Back 75

more toward the surface

examples: skin, oral axillae

Front 76

What is acceptable temperature for humans?

Back 76

96.8-100.4

Front 77

What is thermoregulation?

Back 77

the balance between heat lost and heat produced

done by hypothalamus

Front 78

What are some mechanisms of heat loss?

Back 78

sweating
vasodilation
inhibition of heat production

Front 79

What are some mechanisms of heat production?

Back 79

vasoconstriction (which reduces blood flow to skin and extremities)

voluntary muscle contraction & shivering

Front 80

When does shivering begin?

Back 80

when vasoconstriction is ineffective in preventing additional heat loss

Front 81

What is basal metabolism?

Back 81

the amount of heat produced by the body at absolute rest

Front 82

An involuntary body response to temperature differences in the body.

It requires a significant amount of energy.

Back 82

shivering

Front 83

What is nonshivering thermogenesis?

Back 83

occurs primarily in neonates. Because they can not shiver, a limited amount of vascular brown tissue, present at birth, is metabolized for heat production.

Front 84

What are the list of four types of heat loss?

Back 84

radiation

conduction

convection

evaporation

Front 85

The transfer of heat from the surface of one object to the surface of another without direct contact between the two.

Back 85

Radiation, up to 85% of the body's surface radiates heat to the environment.

Front 86

Give an example of affecting radiation in a patient.

Back 86

removing blankets will increase heat loss thru radiation

standing up increases radiation, fetal position decreases radiation

Front 87

The transfer of heat from one object to another WITH DIRECT CONTACT.

Back 87

Conduction

Front 88

Give an example of conduction with a patient.

Back 88

ice pack on leg

aquatermia pad

Front 89

Transfer of heat away by air movement.

Back 89

Convection (fan)

increases when moistened skin comes into contact with slightly moving air

Front 90

Transfer of heat energy when a liquid is changed to a gas.

Back 90

Evaporation

-600-900ml a day evaporates from the skin

Front 91

Heat loss mechanisms couldn't keep pace with the excess amount of heat produced.

Back 91

Pyrexia or fever

Front 92

List the four types of fevers:

Back 92

Sustained -

Intermittent

Remittent

Relapsing

Front 93

Sustained Fever

Back 93

constantly above 100.4, no changes

Front 94

Intermittent Fever

Back 94

spikes and drops to normal within 24 hours

Front 95

Remittent Fever

Back 95

Spikes & Falls w/ out return to normal

Front 96

Relapsing Fever

Back 96

Febrile & normothermia in spans greater than 24 hours (might take a day or two to peak and fall)

Front 97

Give the ranges for:

low grade fever

high grade fever

hyperpyrexia

Back 97

low grade: 98.8-100.6

high grade: >100.6

hyperpyrexia >104.9

Front 98

For every degree of temperature, we need ______ more O2 at a cellular level.

Back 98

13%

Front 99

Describe heat stroke.

Back 99

heat stroke: prolonged exposure to sun or high environ. temps that overwhelm the body's heat loss mech.

S/S: giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances and even incontinence.

Front 100

Describe heat exhaustion.

Back 100

profuse diaphoresis results in excess water and electrolyte loss.

s/s of FVD: (equal loss of water and electrolytes): tachycardia, dry mm, thirst, poor skin turgor, oliguria, slow filling peripheral veins, neuro changes: lethargy, confusion, pulse up, bp down

Front 101

What are the CORE body temp ranges that signal hypothermia?

Back 101

96.8 and below...

moderate 93.2

severe 86.0

Front 102

What is frostbite?

Back 102

ice crystals forming inside the cell

Front 103

What are the stages of a febrile episode?

Back 103

chill

fever (plateau)

flush

Front 104

Describe chill phase

Back 104

body trying to increase core body temperature; pale, cool skin, shivers, goose-flesh c/o bbeing cold

Front 105

Describe fever phase.

Back 105

temp reached new higher set point, warm to touch, flushed, increased thirst, malaise, weakness, achy, drowsy or restless

Front 106

Describe flush phase.

Back 106

diaphoresis, decreased shivering, flushed, warm to touch

Front 107

Interventions for chill stage

Back 107

apply blankets
increase intake
restrict activity
supplemental o2

Front 108

Interventions for fever phase

Back 108

cover lightly
avoid chilling
increase intake
apply lubricate to lips and nares
use tepid sponge bath
increase air circulation to hasten cooling

Front 109

Interventions for flush phase

Back 109

use tepid sponge bath
avoid chilling
increase intake
restrict activity
cover lightly with clothing/linen

Front 110

When do you cover?

Back 110

chill phase (extra blankets)
fever phase (lightly)
flush phase (lightly)

Front 111

When do you bathe?

Back 111

fever, flush phase, never chill phase

Front 112

Increased neutrophils

Back 112

bacterial

Front 113

Increased lymphocytes

Back 113

viral

Front 114

What is important to remember about the ND: impaired skin integrity?

Back 114

need location

:sacrum
:perianal

Front 115

Remember that with risk for infection, this is the one you use for....

Back 115

surgical incisions. DO NOT use impaired skin integrity