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Penetrating wounds A wound that enters the interior of an organ or cavity
Arterial Insufficiency Ulcers recommendations Avoid unnecessary leg elevation, avoid using heating pad or soaking feet in hot water
Venous insufficiency Ulcers recommendations Compression to control edema Elevate legs above the heart Attempt active exercise include ROM
Neuropathic Ulcers description Areas of the foot, well-defined callused rim, cracked periwound tissue, good granulation, low to mod exudate, no pain, absent pulse, normal edema, decreased skin temp., dry inelastic, shiny skin, loss of protective sensation
Arterial Insufficiency description lower one-third of leg, toes Smooth well defined edges, deep minimal exudate Severe pain normal edema decreased skin temperature Thin and shiny, hair loss, yellow nails, Leg elevation increases pain
Venous insufficiency ulcers description Proximal to medial malleolus, irregular shape, shallow, moderate/heavy exudate, normal pulses, mild to moderate pain, increased edema, flaky, dry skin, brownish discoloration, leg elevation lessens pain
Partial-thickness wound Extends through the epidermis and possible into, but not through the dermis
Full-thickness wound Extends through the dermis into deeper structures such as subcutaneous fat
Subcutaneous Wound Subcutaneous wounds extend through integumentary tissues and involve deeper structures such as subcutaneous fat, muscle, tendon, or bone
Seropurulent Presents as cloudy or opaque, with a yellow or tan color and a thin, water consistency
Purulent Presents with a yellow or green and a thick, viscous consistency.
Hyperkeratosis Referred to as a callus, is typically white/gray in color and can vary in texture from firm to soggy
Ecchymosis The discoloration occurring below intact skin resulting from traum to underlying blood vessels and blood seeping into tissues. Referred to as a bruise
Normotrophic Scar A scar characterized by the organized formation of collagen fiber that align in a parallel fashion
Turgor The relative speed with which the skin resumes its normal appearance after being pinched
Superficial partial-thickness Burn Involves the epidermis, and the upper portion of the dermis, may be extremely painful and exhibit blisters
Deep partial-thickness Burns Involves complete destruction of the epidermis and the majority of the dermis. Discolored with broken blisters and edema. Damage to nerve ending result in moderate pain
Full-thickness Burn Involves complete destruction of the epidermis and dermis along with partial damage to the subcutaneous fat layer. Eschar formation and minimal pain
Subdermal Burns The complete destruction of the epidermis, dermis, and subcutaneous tissue. May involve muscle and bone tissue
Rules of nines - head and neck 9
Rules of nines - anterior trunk? Posterior trunk? 18 and 18
Rules of nines - Bilateral anterior arm, forearm, and hand? Posterior? 9 and 9
Genital region 1
Rules of nines - Bilateral anterior leg and foot? posterior? 18 and 18
How much pressure is needed to create an environemt that facilaties the balance of collagen synthesis and lysis 15-35 mm Hg
Cellulitis Results from a bacterial infection -localized redness, warm or hot skin, local abscess or ulceration, tenderness to palpation, chills, fever, malaise
Contact Dermatitis A superficial irritation of the skin from localized irritation -intense itching, burning, red skin, local edema
Eczema known as dermatitis, chronic skin inflammation typically due to an immune system ambnormality, allergic rxn or external irritant -Red or brown-gray, itchy, lichenified skin plaques
Gangrene (Dry) When there is a loss of vascular supply resulting in local tissue death. -Dark brown or black nonviable tissue that becomes hardened, cold or numb skin, maybe pain
Gangrene (Wet) Associated with a bacterial infection -swelling and pain at the site of infection, change is skin color from red to brown to black, blisters, pus, fever and malaise
Plaque Psoriasis Chronic autoimmune disease -raised red blotches that present in a bilateral fashion. Itchy and flaky
Metabolic Alkalosis An increase bicarbonate or loss of acid Nausea, diarrhea, confusion, muscle fasciculations, cramping, convulsions, and hypoventilation
Metabolic Acidosis Accumulation of acids; assoc. renal failure, diabetic or alcoholic ketoacidosis -hyperventilation, vomiting, diarrhea, headache, weakness, and malaise, cardiac arrhythmias
Addison's Disease Hypofunction of the adrenal Cortex -Hypotension, weakness, anorexia, weight loss, altered pigmentation
Cushing's Syndrome Hyperfunction of the adrenal gland -hyperglycemia, growth failure, obesity, moon shaped face, buffalo hump on the neck, weakness, acne, hypertension, and male gynecomastia
Hypothyroidism fatigue, weakness, decreased heart rate, weight gain, constipation, delayed puberty, and retarded growth and development
Hyperthyroidism Increased nervousness, excessive sweating, weight loss, increase in blood pressure, exophthalmos, myopathy, chronic periarthritis, and an enlarged thyroid gland -Graves disease
Created by: ckdabne