MCC fall10 block 1 kozier ch 36
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| List the 5 factors that affect skin integrity... | show 🗑
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| show | those who are at an advanced age, immobile, have diminished sensations, excessive body heat, poor nutrition, incontinence, & decreased mental status
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| show | 4 Stages
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| Describe a Stage 1 pressure ulcer: | show 🗑
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| show | Partial-thickness skin loss involving epidermis and possibly dermis.
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| Describe a Stage 3 pressure ulcer: | show 🗑
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| Describe a Stage 4 pressure ulcer: | show 🗑
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| External causes of pressure ulcers | show 🗑
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| show | 1. Provide proper nutrition, 2. maintain skin hygiene, 3. avoid skin trauma, 4. provide supportive devices
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| show | The tissue surface is closed, there is minimal or no tissue loss, and there is formulation of granulation and scarring.
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| Describe Secondary wound healing characteristics. | show 🗑
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| show | The wound is initially left open, edema, infection, or exudate resolves and then the wound is closed.
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| Identify the three major types of exudate. | show 🗑
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| What are the characteristics of Serous exudate? | show 🗑
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| What are the characteristics of Purulent exudate? | show 🗑
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| What are the characteristics of Sanguineous exudate? | show 🗑
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| What are the complications associated with would healing? | show 🗑
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| show | 1. age, 2. nutrition, 3. lifestyle, 4. medications.
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| show | Check location, extent of tissue damage, wound LxWxD, bleeding, foreign bodies, any associated injuries, and last tenus shot.
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| Identify assessment data for treated wounds. | show 🗑
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| Name the three phases of wound healing. | show 🗑
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| Describe the Inflammatory Phase of wound healing. | show 🗑
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| Describe the Proliferative Phase of wound healing. | show 🗑
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| show | Occurs around day 21 until 1/2 years post injury. Collagen is structured/organized (not blotchy) and the wound is remodeled and contracted. Scarring is formed.
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| RYB color guide to wound care means: | show 🗑
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| show | Increase fluid intake, monitor zinc, protein, and vitamins, get dietary consult (supplements) monitor weight/lab values, prevent microorganisms, and transmission of pathogens.
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| show | Transparent film (protection), impregnated non-adherent (cover wounds w/o exudate), hydrocolloids (absorbs), clear absorbant acryllic (bacterial/shearing protection), hydrogel (liquiefy naecrotic) , polyurethane foam (absorb), alginate (ordor absorbing)
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| show | Gauze, elasticized, and binders (girdles)
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| Gauze bandage is used for... | show 🗑
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| show | To provide pressure to an area, and improve venous circulation in legs
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| show | The support of large areas of the body. Ex: Girdle and triangular arm sling.
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| What are the indications for using a HEAT? | show 🗑
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| What are the effects of using HEAT? | show 🗑
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| What are the indications for using COLD? | show 🗑
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| show | Vasoconstriction, decrease in capillary permeability, decrease in cellular metabolism, slows bacterial growth, and decreases inflamation. Has a local anesthetic effect
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| Cold application ranges: Celcius | show 🗑
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| Heat application ranges: Celcius | show 🗑
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| show | Herpes Zoster and Herpes Simplex
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| show | an infection caused by varicella zoster virus "shingles"
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| Herpes simplex | show 🗑
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| Tinea type infections are what type? bacterial or fungal? | show 🗑
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| Tinea Pedis is | show 🗑
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| show | Ringworm of the body
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| show | Ringworm of the scalp
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| show | Ringworm of the groin
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| show | Infestation with lice
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| show | Scabies
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| Chronic Venous Insufficiency (CVI) is when.. | show 🗑
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| An increases in venous pressure equals | show 🗑
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| show | cellular death
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| What is happening when a patient exhibits hard, shiny skin? | show 🗑
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| When RBC's begin to breakdown skin starts to look ... | show 🗑
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| show | Peripheral Vascular Disease
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| Signs of PVD | show 🗑
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| Signs of Venous Ulcers with CVI | show 🗑
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| Signs of Arterial Ulcers with CVI | show 🗑
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| show | Elevate legs, Walk/avoid long periods of sitting/standing, No leg cross, no restrictive clothes, TED hose when prescribed, keep skin clean/soft/dry, prevent injury & inspect daily
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| show | NS wet/moist gauze dressings, possible diluted topical antibiotic, Unna boot (Semirigid) padded bony parts, changed 1/2weeks, hyperbaric chamber, surgery for large non healing areas
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| Common types of venous insufficiency include... | show 🗑
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| List the six types of wounds | show 🗑
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| show | an open wound; deep or shallow, caused by a sharp instument, knife/scalpel
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| show | a closed wound, skin appears bruised (ecchymotic) due to damaged blood vessels, caused by a blow from blunt instrument
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| An abrasion is | show 🗑
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| show | and open wound, penetration of the skin and underlying tissue caused by a sharp instrument
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| show | open wound with jagged edges due to tissue being torn apart usually from accidents (machinery)
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| show | an open wound that usually penetrates the skin and underlying tissue and is usually unintentional (a shooting)
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| show | a deficiency in the blood supply to the tissue.
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| show | issue softened by prolonged wetting or soaking. Incontinence can cause this.
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| What is excoriation? | show 🗑
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| what is hemostasis? | show 🗑
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| What is a Keloid? | show 🗑
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| show | A bruise. Collection of blood underneath the skin.
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| The partial or total rupturing of a sutured wound is called... | show 🗑
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| show | evisceration. When the inside of a wound is popping out.
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| show | When you remove dead tissue/necrotic nonviable tissue from a wound.
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| NANDA Diagnosis: "Risk for Impaired Skin integrity" relates to | show 🗑
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| show | Altered epidermis and/or dermis. Applies to pressure ulcers and to wounds extending through the epidermis but not through the dermis.
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| show | Damage to mucous membranes, corneal, integumentary, or subcutaneous tissue. Applies to pressure ulcers and wounds extending to subq tissue, muscle, or bone
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| Teaching skin integrity. To maintain intact skin educate about | show 🗑
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| show | Nutrition (protein, vit b/c, iron, hydration. Instruct in wound assessment/documenttion, asepsis hand hygiene, s/s of wound infection to report, prevention, demonstrate wound care techniques, pain control
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