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39 Cards in this Set
- Front
- Back
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Stage I Pressure Ulcer
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intact skin w/ non-blanchable erythema
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Stage II Pressure Ulcer
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abrasion, shallow crater/blister
Partial-thickness loss involving epidermis, dermis/both |
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Stage III Pressure Ulcer
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full-thickness tissue loss
subcutaneous fat visible |
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Stage IV Pressure Ulcer
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full-thickness tissue loss
muscle/bone visible |
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Primary Intention Healing
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wound closed; healing occurs by epithelialization
ex=surgical wound |
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Secondary Intention Healing
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wound edges not approximated
heals by granulation tissue formation EX: burn, pressure ulcer |
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Tertiary Intention Healing
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would left open for several days then edges approximated
EX: contaminated wounds requiring observation |
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partial-thickness wound
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shallow; loss of epidermis & possibly partial dermis loss; heals by regeneration
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Full-thickness wound
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extend into dermis; heals by scar formation
EX: pressure ulcer |
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Components of healing process
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(1) Inflammation- injury to 2/3 days; redness, edema, warmth, throbbing
(2) Proliferation- wound closes, fills w/ granulation tissue, collagen formation (3) Remodeling- from time wound closes lasting up to 2yrs |
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Complications of Wounds
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Hemorrhage- bleeding
Hematoma- blood tumor; result of internal bleeding Infection- >10 to the 5th org/gram tissue Dehiscense- edges no longer approximated Evisceration- medical emergency; protrusion of visceral organ Fistula- fluid in wound creates false canal |
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Circadian rhythms
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factor that affects sleep
24 hr, day/night cycle influence pattern of major biological & behavioral functions light, temp, social activities & work routines affect |
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Nursing Interventions for Sleep
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-environmental controls
-bed time rituals -comfort -establish periods of sleep & rest (nurse primarily involved here) -snacks in early evening & early cessation of caffeine -stress reduction -work with physiological problems -teaching -medication (last resort; for short periods) |
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Acute/Transient Pain
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-protective pain of short duration
-known cause -limited tissue damage & emotional response -resolves w/w/o treatment when injury heals (can progress to chronic pain) |
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Chronic/Persistent Pain
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-isn't protective; serves no purpose
-not always an identifiable cause -major cause of psychological & physical disability - pt suffers more w/ time from mental & physical exaustion |
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Sympathetic Stimulation for Pain
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-pain of low-moderate intensity & superficial pain
-increased resp rate, HR, BP, blood glucose, muscle tension -pallor -diaphoresis (to control body temp) -pupil dilation -decreased GI mobility (to free energy for immediate activity) |
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Parasympathetic Stimulation for Pain
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-severe & deep pain
-pallor (blood shifting away from periphery) -muscle tension (from fatigue) - decreased HR & BP -rapid/irregular breathing (causes body defenses to fail under prolonged stress from pain) |
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Nonpharmacological Pain Relief Interventions
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(1) cognitive behavioral & physical approaches
-GOALS: change client's perception of pain, alter pain behavior, provide clients with greater sense of control -IE: distraction, relaxation, guided imagery, biofeedback (2)physical approaches -GOAL: provide pain relief, correct physical dysfunction, alter physiological response, reduce fear -IE: chiropractic therapy/acupuncture |
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Relaxation
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-Nonpharmacological pain relief intervention
- helps client alter affective-motivational & cognitive pain perception -Relaxation: mental & physical freedom from tension/stress that provides pt with sense of self-control -associated changes: decreased pulse, BP, respirations, muscle tension, metabolic rate & O2 consumption, sense of peace, heightened global awareness -EX: guided imagery, meditation, progressive relaxation |
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Distraction
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-Nonpharmacological pain relief intervention
-RAS inhibits painful stimuli if person receives sufficient sensory input -works best for short, intense pain lasting few minutes EX: music |
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Cutaneous Stimulation
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-Nonpharmacological pain relief intervention
-stimulation of skin helps relieve pain by reducing muscle tension & pain perception EX:massage,warm bath, ice bag |
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massage
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-Cutaneous Stimulation measure to reduce pain
- effective for producing physical & mental relaxation, reducing pain & enhancing effectiveness of pain meds |
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Cold & Heat Application
(to reduce pain) |
- Cutaneous Stimulation measure to reduce pain
-relieve pain & promote healing Cold: pain relief; apply near site |
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Reducing Pain Perception
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-removing/preventing painful stimuli
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Transcutaneous Electrical Nerve Stimulation (TENS)
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-Cutaneous pain relief intervention
-stimulates skin w/ mild electric currents passed through external electrodes -effective for post-surgical & procedural pain control |
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Principles of Surgical Asepsis
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1. sterile object remains sterile only when touched by another sterile object
2. only sterile objects placed on sterile field 3. sterile object/field out of range of vision/held below waist contaminated 4. sterile object/field contaminated from prolonged exposure to air 5.sterile object/field comes into contact w/ wet surface, contaminated 6. fluid flows in direction of gravity 7. 1in edge border of sterile field/container contaminated |
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Pain Impulse Travel**
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-A-delta & C-fibers>peripheral tissues>dorsal root>dorsal horn>spinothalmic tract>brain stem>thalamus
(pain sensation is relayed through peripheral nerves, spinal column to the brain. ) -Spinothalamic Tract |
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Modulation
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The enhancement & inhibition of pain impulses at all levels of the CNS.
The brain has the ability to pay selective attention to certain stimuli and ignore others. |
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Endorphins
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endogenous opioid receptors responsible for analgesia
- body able to produce neurotransmitters such as these to modulate pain relief |
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Gate Control Theory of Pain
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Dorsal horn cells act as a gate: Closing to prevent nociceptive impulses from reaching the brain or opening to allow impulses to be transmitted to the brain.
A-delta & C-fibers - open gate Alpha & beta fibers - close gate |
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Pain Threshold
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amount of pain
stimulation that a person requires before feeling it. |
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Pain Tolerance
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highest intensity
of pain that the person is willing to tolerate |
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Malignant Pain
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persistent chronic pain and acute pain associated withprogressive process
"intractible” EX: arthritis & cancer |
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Pain Epidemic
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More people > 45 “magic age” for chronic pain vulnerability
More people surviving accidents More with degenerative disease More are sedentary and overweight More suffer chronic high stress |
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allodynia
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chronic pain due to nonpainful stimulus
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hyperalgesia
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increased pain sensitivity
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Contralateral Stimulation
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-pain relief intervention
-the opposite area is stimulated with pressure, massage, heat, or cold casts & bandages useful for cramps, spasms, & itching |
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Opiods ( narcotics)
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-cause CNS depression; dangerous to respiratory system
-we MUST screen for respiratory depression meaing bradypnea and or apnea after narcotics. -constipating |
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Patient Controlled Analgesia ( PCA)
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Intravenous pump that employs a computer to inject tiny amounts of drug when they patient depresses a button.
-monitor for side effects, efficacy |
