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83 Cards in this Set
- Front
- Back
the bright red flush which appears after circulation is reestablished
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hyperactive erythema
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how long does hyperactive erythema last?
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usually one-half to three-quarters as long as the duration of impeded blood flow to the area
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other names for pressure ulcers are:
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-decubitus ulcer
-bedsores -pressure sores |
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what are the 4 terms used to describe wounds based on their relative degrees of contamination?
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-clean wounds
-clean-contaminated wounds -contaminated wounds -dirty or infected wounds |
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skin on the legs which appears shiny, with hair loss, and easily damaged may indicate this condition
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impaired peripheral arterial circulation
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what effect does coritcosteroids have on the skin?
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they thin the skin
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an open wound caused by a sharp instrument
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incision
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a type of wound caused by a blow from a blunt object
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contusion
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an open wound caused by a surface scrape
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abrasion
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an open wound caused by tearing tissues apart
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laceration
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an open wound caused by the penetration of the skin by a sharp object in a stabbing motion
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puncture
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an open wound caused by something like a bullet or metal fragment
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penetrating wound
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a force acting parallel to the skin surface
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friction
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a combination of friction and pressure
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shearing force
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how does shearing force damage tissue?
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it moves the superficial tissue farther in a direction than the deep tissue, causing a separation of the two layers
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"partial thickness" means what when referring to wounds?
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that the damage is confined to the skin (the dermis and epidermis)
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"full thickness" means what when referring to wounds?
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that the damage goes deeper than the skin and extends into subcutaneous tissue and possibly muscle and bone
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prolonged inadequate nutrition have these effects which increase the risk for pressure ulcers
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-weight loss
-muscle atrophy -loss of subcutaneous tissue |
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stage 1 pressure ulcer is characterized by
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nonblanchable erythema
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stage 2 pressure ulcer is characterized by
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partial thickness skin loss involving the epidermis and possibly the dermis
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stage 3 pressure ulcer is characterized by
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full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
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stage 4 pressure ulcer is characterized by
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full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures
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undermining may be present in which stage(s) of pressure ulcers?
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stage 3 and stage 4
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what are the changes in skin which make older people more prone to impaired skin integrity?
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-loss of lean body mass
-generalized thinning of epidermis -decreased strength and elasticity of skin -increased dryness (less oil) -diminished pain perception |
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the process of softening tissue by soaking or prolonged wetting
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maceration
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a "denuded area" is an example of this
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excoriation
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macrophages engulf debris by a process known as
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phagocytosis
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macrophages secrete this, which stimulates the formation of epithelial buds at the ends of damaged capillaries
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AGF (angiogenesis factor)
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a layer of dried plasma proteins and dead cells
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eschar
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a translucent red tissure which appears during the proliferative phase characterized by its fragility and network of new capillaries
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granulation tissue
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this type of exudate consists of large amounts of red blood cells
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sanguineous exudate
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this type of exudate is thicker than serous exudate which can vary in color and can be blue, green, or yellow
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purulent exudate
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the process of pus formation is called
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suppuration
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if a bacteria causes pus, it can be said to be______..
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pyrogenic
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a clear exudate formed from serum
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serous exudate
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the clear part of the blood is called______.
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serum
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a localized collection of blood underneath the skin
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hematoma
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the cessation of bleeding is called ________.
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hemastasis
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this type of healing occurs when the edges of a wound have been approximated
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primary intention healing
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this type of healing occurs when the edges cannot or should not be approximated
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secondary intention healing
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bright sanguineous bleeding indicates this
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fresh bleeding
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during the inflammatory phase of wound healing, two major processes occur which are:
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hemostasis and phagocytosis
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hemostasis occurs because of (4 events)
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-vasoconstriction of large blood vessels
-retraction of injured blood vessels -deposition of fibrin -blood clotting |
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true or false? after hemostasis, epithelial cells migrate into the wound from the edges.
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true. beneath the scab, epithelial cells migrate into the wound from the edges
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this type of cell arrives at the wound at about 24 hrs after injury
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macrophages
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the second phase of wound healing is called this ______.
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proliferative phase
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the proliferative phase begins at about how long after injury?
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it begins about 3 or 4 days after injury
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how long does the proliferative phase last?
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about 18 days
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a whittish protein substance secreted by fibroblasts
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collagen
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the last phase of wound healing is called______.
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maturation phase
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the maturation phase of the healing process begins at about how long after the injury?
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it begins about 21 days after injury
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how long does the maturation phase last?
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it can last one or two years after the injury
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what occurs during the maturation phase?
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-collagen continues to be synthesized
-collagen fibers are rearranged into a more orderly structure -the wound is remodeled and contracted -the scar becomes stronger |
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true or false? a scar formed because of a wound is actually stronger than the skin that was there before the damage.
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false. the scar is never as strong as the skin that was previously there
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another name for a hypertrophic scar
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keloid
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in what ways does bacterial contamination effect wound healing?
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-bacteria depletes the new cells' O2 and nutrients
-bacteria produces by-products which can interfere with a healthy surface condition -can lead to infection |
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what distinguishes bacterial contamination from infection?
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when the microorganisms multiply rapidly or invade tissues, infection occurs
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what are some suggestions of wound infection?
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change in wound color, pain, or drainage
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the Braden scale is used to describe what?
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the level of risk that a client is at for developing pressure ulcers
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what are some signs of shock
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-rapid thready pulse
-cold clammy skin -pallor -lowered blood pressure |
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measures to control severe bleeding include:
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-applying direct pressure over the wound
-elevating the involved extremity |
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what effect does obesity have on wound healing and why?
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-slower healing
-increased risk of infection -because adipose tissue has poor vascularization |
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how does smoking influence wound healing and why?
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-slows healing
-increased risk of infection -because smoking reduces the amount of functional hemoglobin in the blood and constricts arterioles |
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how does regular exercise affect wound healing and why?
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-faster healing
-decreased risk of infection -because those who exercise regularly tend to have good circulation |
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how might prolonged use of antibiotics make a person suceptible to wound infection?
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by destroying microorganisms which compete with, or are antagonistic to, resistant organisms
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the surface temperature of a pressure ulcer should be what
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it should be the same temp as the normal skin around it. increased temp is an indication of infection or blood trapped deep to the skin
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diabetes and cvd might influence wound healing how? and why?
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-it might slow it due to impaired O2 delivery
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using the ryb color code of wounds, how would you treat a wound with all three colors?
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-debride the black first
-cleanse the yellow next -protect the red last |
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what methods might be used to perform "mechanical debridement" on a wound?
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-scrubbing
-wet to damp dressings |
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what is the most selective form of debridement?
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autolytic debridement
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transparent wound barriers offer several advantages which are:
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-acts as temporary skin
-are nonporous, self-adhesive -do not require changing -the wound can be assessed while wearing because they are transparent -wound remains moist and retains serous exudate, which promotes epithelial growth -they are elastic and do not restrict mobility -do not adhere to wound -client can shower/bathe with them on -they can be removed without damaging wound tissues |
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this type of dressing is used to liquify necrotic tissue, rehydrate the wound bed, and to fill in dead space
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hydrogels
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this type of wound dressing is used to absorb light to moderate amts of exudate. it must have its edges taped down and requires a second dressing to obtain an occlusive environment.
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polyurethane foams
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what aspects should be assessed before teaching clients and family members to change dressings and wraps
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-their willingness and ability to change them?
-what kind of support people do they have? -do they have proper supplies, and know where to get more supplies? |
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how does the length of exposure affect a person's tolerance to heat/cold?
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tolerance increases with increased exposure to heat/cold
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how does the size of the exposed area affect tolerance of heat/cold?
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the greater the size of the exposure, the lower the tolerance
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how does intactness of skin affect tolerance to heat/cold?
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injured skin areas are more sensitive to temperature variations
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how does age influence tolerance to heat/cold?
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the very young and very old generally have the lowest tolerance to heat/cold
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True or false? the back of the hand and back of the feet are more sensitive to heat and cold than the inner aspect of the wrist and forearm.
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False. The inner aspect of the wrist and forearm and the perineum are more sensitive to heat/cold than are the backs of the feet and hands
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suture and staple removal may be done by whom?
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any liscensed personel (rn's and lpn's)
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NAII's can do what type of dressing change?
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one that does not require sterile technique....wound over 48 hrs old
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when bandaging a limb, how should the limb be positioned when bandaging?
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it should be in its normal position with the joint slightly flexed to avoid putting strain on the ligaments and muscles
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in which direction should you bandage?
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from the distal to the proximal end of the extremity to aid in return venous flow
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