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38 Cards in this Set
- Front
- Back
__ is a chronic ulcer commonly located on the distal medial aspect of the lower leg and is associated with stasis dermatitis.
-stasis ulcer -decubitus ulcer |
stasis ulcer
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stasis ulcers are often preceded by __ and ____.
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stasis dermatitis and relatively minor trauma
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are SU's typically __ and __
-shallow and stay the same size -deep and penetrating |
shallow and stay the same size but can increase in size quickly with inc. edema or infection
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__ typically occur over bony prominences such as sacrum, ischial tuberosities, trochanters, ankles, and heels.
-stasis dermatitis -stasis ulcers -decubitus ulcers |
decubitus ulcers
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A nonblanchable erythema seen over intact skin, is a ....
-stage 1 DU -stage 2 DU -stage 3 DU -stage 4 DU |
stage 1 DU
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In a nonhealing SU a tissue __ or __ may be necessary to determine infection or malignancy.
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culture or biopsy
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t/f
ulcers of the lower extremity are often caused by more than one etiology |
true; most are making diagnosis more complicated
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__ ulcers are often assoc. with diabetes and loss of sensation in the lower extremities.
-venous -neuropathic -arterial |
neuropathic
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t/f
there is a high rate of recurrence of SU |
true
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what two studies are done to delineate the degree of venous or arterial disease?
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venous doppler
ankle-brachial index |
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when should pt's with SU get antibiotics?
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when a tissue culture directs that type of therapy.
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what type of ulcers are assoc. with pain, decreased pulses, and cool extremities.?
-arterial -venous -neuropathic |
arterial
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__ ulcers occur over pressure points and are surrounded by a thick callous.
-arterial -venous -neuropathic |
neuropathic ulcers
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__ ulcers are often assoc. with diabetes, and loss of sensation in the lower extremities.
-arterial -venous -neuropathic |
neuropathic ulcers
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before aggressive compression therapy is initiated, __ disease should be excluded.
-arterial -venous -neuropathic |
arterial disease patients should not have compression therapy
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t/f
compression therapy is recommended with SD and SU |
true
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when is skin grafting considered in a stasis ulcer?
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when the pt fails to respond to compression therapy and other tx modalities.
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what is key in with SU?
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prevention
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t/f
reducing edema and stasis dermatitis reduces the incidence of SU. |
true
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__ are localized areas of tissue destruction caused by prolonged pressure usually over a bony prominence.
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decubitus ulcers
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what bony prominences do DU usually occur over?
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ischial tuberosities
sacrum trochanters ankles heels |
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a nonblanchable erythema seen over intact skin is what stage of DU?
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stage 1
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an ulceration extending to the subcu layer is what stage of DU?
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stage 3
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an ulceration of epidermis, dermis, or both is what stage of DU?
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stage 2
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an ulceration extending to muscle, bone, and/or supporting tissues is what stage of DU?
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stage 4
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what pt's are at increased risk of developing DU's?
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immobile
incontinent poor nutrition poor circulation profound sensory deficits |
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__ exert forces parallel to the skin causing stretching or tearing of underlying blood vessels and reducing the amount of pressure necessary to cause tissue ischemia.
-shear forces -pressure -friction |
shear forces
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what are the major contributing factors resulting in DU's?
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pressure
shear friction moisture |
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__ over a bony prominence, causes soft tissue compression and interferes with the tissue blood supply.
-shear forces -pressure -friction |
pressure
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__ can occur when the head of a pt's bed is elevated causing the pt to sit on an incline for prolonged period of time.
-shear forces -pressure -friction -moisture |
shear forces
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what scales are used in the prediction of decubitus ulcer risk?
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braden and/or norton
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DU's typically occur in the elderly but can occur in pt's with significant __ disease.
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neurologic
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what is the goal of treatment of stage 1 and 2 DU's?
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assessing and correcting risk factors
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how are stage 2 DU's typically treated?
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using an occlusive drsg and avoiding all pressure to the area.
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the presence of necrotic tissue, exudates, or evidence of infection usually requires what kind of tx?
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debridement
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stage 3 and 4 DU's usually require what type of mgt?
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wound care specialist care
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what type of surgical procedures can be therapeutic in the tx of DU's?
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skin grafts or flap closures
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shear and friction are increased with mild to moderate ___
pressure moisture movement |
moisture
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