Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
AH- CH 48
Adult Health I
| Question | Answer |
|---|---|
| wound drainage: clear, watery plasma | serous |
| wound drainage: thick, yellow, green, tan, or brown | purulent |
| wound drainage: pale, red, watery: mixture of clear and red fluid | serosanguineous |
| wound drainage: bright red: indicates active bleeding | sanguineous |
| hyperemia | redness |
| occurs when the normal red tones of the light-skinned client are absent | blanching |
| 3 pressure-related factors to pressure ulcer development | 1. pressure intensity 2. pressure duration 3. tissue tolerance |
| why should you avoid using a florenscent light when assessing dark skinned pt? | b.c it makes blue tones |
| what are risks for pressure ulcer development? | impaired sensory perception, impaired mobility, alteration in LOC, shear, friction, moisture |
| intact skin with nonbla nchable redness of a localized area | stage 1 pressure ulcer |
| partial-thickness skin loss involving the epidermis or the dermis or both--superficial and presents as a abrasion, blister, or shallow crater | stage 2 pressure ulcer |
| full-thickness tissue loss, subq fat may be visible--may include undermining and tunneling | stage 3 pressure ulcer |
| full-thickness tissue loss with exposed bone, muscles, or tendons--often includes tunneling and undermining | stage 4 pressure ulcer |
| red moist tissue composed of new blood vessels--reps healing | granulation tissue |
| stringy substance attached to wound bed that is either soft yellow or white | slough |
| black or brown necrotic tissue in the wound bed | eschar |
| trauma or surgical incision wound | acute |
| vascular compromise, chronic inflammation or repetitive insults to the tissue | chronic |
| wound that is closed | primary intention |
| wound edges are not approximated | secondary intention |
| wound left open for several days, then wound egdes are approximated | tertiary intention |
| wounds that are contaiminated and require observation for signs of infammation | tertiary intention |
| pressure ulcers, surgical wounds that have tissue loss | secondary intention |
| surgical incision, wound that is sutured or stapled | primary intention |
| what are the 3 componets in the healing process of partial-thickness wounds | 1. inflammation response 2. epithelial proliferation and migration 3. reestablishment of the epidermal layers |
| what are the 3 componets in the healing process of full-thickness wounds | 1. inflammation process 2. proliferation 3. remodeling |
| is a localized collection of blood underneath the tissue | hematoma |
| is the partial or total seperation of wound layers | dehiscence |
| protrusion of viseral organs through a wound opening | evisceration |
| is an abnormal passage between 2 organs or between an organ and the outside of the body | fistula |
| is a protein formed from amino acids aquired by fibroblasts from protein ingested in food | collagen |
| necessary for synthesis of collagen | vit C |
| reduces the negative effect of steroids on wound healing | vit A |
| is necessary for epitheliazation and collagen synthesis | zinc |
| necessary for collagen fiber linking | copper |
| provide the material needed to support the cellular activity of wound healing | calories |
| biochemical indicators of malnutrition | serum proteins |
| reflects what protein the pt has ingested, absorbed, digested, and metabolized | prealbumin |
| is superficial with little bleeding and is considered a partial-thickness wound | abrasion |
| bleeds more profusely, depending on the wound's depth and location | laceration |
| wounds bleed in realtion to the depth and size of the wound | puncture |
| norton scale scores what 5 things? | phy condition, mental condition, activity, mobility, and incontinence |
| Braden scale scores what 6 things? | sensrpy perception, moisture, activity, mobility, nutrition, and friction/shear |
| nortons scale range? | 5-20 |
| bradens scale range? | 6-23 |
| risk for pressure ulcer on norton scale is ___ | 14 |
| risk for pressure ulcer on braden scale is ___ | 18 |
| jhf | hgvh |
Created by:
TayBay15
Popular Nursing sets