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