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40 Cards in this Set

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Name some age related changes that happen to skin.
- decrease in skin elasticity
- decrease in collagen
- attachment b/w epidermis and dermis is flattened
- impaired immune response
- decrease in hypodermis
- decrease nutritional intake
What is capillary closing presuure?
it is the minimal amount of pressure required to collapse a capillary.
Name 2 considerations with regard to the duration of pressure.
- low pressure over prolonged period of time causes tissure damage.
- high-intensity pressure over a short period of time causes tissue damage.
What is the best light for checking the skin?
natural/ halogen light
What is the difference between shear and friction?
shear causes deep tissue necrosis and friction affects only the epidermis.
describe the wound classifications by color.
black, yellow, and red.
black- eschar- necrotic tissue
yellow- slough
red- granulation tissue- healing
what is the difference between healing by primary intention and secondary intention.
primary is like with surgery- risk of infection is low
secondary takes longer to heal and filled with scar tissue.
3 components in the healing process of PARTIAL THICKNESS wound.
-inflammatory phase
-proliferative phase (regeneration)
-maturation (remodeling)
what is dehiscence and evisceration?
dehiscence- partial or total separation of wound layers. obese clients are at high risk. shows an increase in serosanguineous drainage.
-evisceration- is protrusion of visceral organs.
nutrition plays are role in wound healing. Name some things to be considered.
need vitamin a and c, zinc, copper, and collagen suffient calories.
people with low albumin levels are at greater risk for pressure ulcers.
why should soap and hot water be avoided in topical skin care for prevention of ulcers?
they cause alkaline residue that discourages growth of normal skin bateria- therefore promoting growth of opportunistic bacteria to enter an open wound.
what should be used as a dry lubricant to help reduce friction?
cornstarch
what is the best positon to prevent pressure ulcers?
a 30 degree lateral position
why are donut shaped cushions avoided for sitting?
they reduce blood supply to the area, resulting in wider areas of ischemia.
why is massaging avoided in reddened areas?
it increases breaks in capillaries in the underlying tissue and increases the risk of injury to underlying tissue and pressure ulcer formation.
what is the difference between pressue relieving devices and pressure reducing devices?
-pressure relieving devices relieve interface pressure below 32 mm hg (capillary closing pressure)
-pressure reducing reduce the interface pressure, but not necessarily below the capillary closing pressure.
which bed is used for a person who has burns, stage III or stage IV ulcers?
air-fluidized beds
which bed is used for a person who has atelectasis and/or pneumonia?
kinetic therapy bed
name 3 other beds used for high risk clients.
-low air loss system- pressure relief device
- foam- only reduces pressure
- static air filled overlays- pressure relief device or reduction (depends)
name some commonly used solutions that are cytotoxic (kill cells) that should NEVER be used to clean granulating wounds.
- Dakin's soln
- acetic acid
- povidone-iodine
- hydrogen peroxide
what is the optimum method to ensure adequate removal of bacteria by irrigation?
use a 19-gauge needle or an angiocatheter and a 35 ml syringe that delivers saline to a pressure ulcer at 8 psi.
what measurement adequately represents tissue loss at a stage I and II?
What measurement represents tissue loss at a stage III and IV?
-for stage I and II surface area represents tissue loss.
- for stage III and IV volume represents tissue loss.
enzyme ointment is used on what area of an ulcer?
only on necrotic areas!
any eschar ulcer has to be debrided except...
a dry necrotic heal ulcer.
name the methods of debridement.
-mechanical- examples are wet to dry, irrigation, and whirpools.
-autolytic- examples are transparent dressings, hydrocolloid dressing.
-chemical- examples are Dakins soln and sterile maggots. require a dr order.
- sharp/ surgical- removing devitalized tissue which is the quickest way.
2 nursing interventions that relate to nutritional status in the treatment of pressure ulcers.
- increase protein intake- it helps rebuild epidermal tissue.
- keep hemglobin levels normal- low hemoglobin leads to futher tissue ischemia.
a puncture wound is allowed to bleed. why?
to remove dirt and other contaminates, like saliva from a dog bite.
a penetrating object should not be removed. why?
removal could cause massive uncontrolled bleeding.
the best dressing for a painful wound is?
hydrogel dressing
what is "dead space"?
it is a cavity remaining in a wound. it should be eliminated by loosely filling all the wound cavity.
what is the wound V.A.C?
it applies localized negative pressure to draw the edges of a wound together.
when using a V.A.C what types of foam can be used and what are they good for?
- black polyurethane foam stimulates granulation tissue and wound contraction.
- white polyvinyl alcohol soft foam is used to prevent granualtion tissue growth.
irrigation of an open wound requires ________ technique.
sterile
what type of suture is best used for a client with a small laceration of the face?
dacron (polyester)- they minimize scar formation.
why is irrigation soln used at body temperature?
it increases comfort and reduces vascular constriction response in tissues.
what is a sling. what does it support?
slings support arms with muscular sprains or fractures.
when are warm applications contraindicated?
when the client has an acute, localized inflammation. like appendicitis b/c the heat could cause the appendix to rupture.
when are cold applications contraindicated?
when the site of injury is already edematous. Also if the client has neuropathy b/c they cannot percieve temperature change. Also if client is shivering it can increase body temp.
what type of therapy is used for a client that had a episiotomy, painful hemorrhoids, or vaginal inflammation?
sitz bath
what is an aquathermia pad used for?
used to treat muscle sprains and areas of mild inflammtion. only use it for 20 to 30 min.