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
Adult Health part 3
Burns, Integumentary, Pre-op, Intra-op, Post-op
| Question | Answer |
|---|---|
| Burn (definition) | Occurs when there is injury to the tissues of the body caused by heat, chemicals, electric current, or radiation |
| Thermal burns | caused by flamed, flash, scald, or contact with hot objects (most common type) |
| Chemical burns | result from tissue injury and destruction from acids, alkalis, and organic compounds |
| Smoke and Inhalation Injury | result from inhalation of hot air or noxious chemicals and can cause damage to the tissues of the respiratory tract |
| Electrical burns | A result of intense heat generated from an electric current. Direct damage to nerves and vessels, causing tissue anoxia and death. |
| Cold Thermal Injury (frostbite) | results in the formation of ice crystals in the tissues and cells |
| How is severity of a burn determined? | depth of the burn extent of the burn location of the burn Pt risk factors |
| Partial-thickness skin destruction includes | First degree and second degree burns |
| First-Degree | superficial epidermal damage with hyperemia |
| Second-Degree | epidermis and dermis involved to varying depth: mild to moderate edema and blisters |
| Full-Thickness skin destruction includes | Third and Fourth degree burns |
| Third and Fourth-Degree | all skin elements and local nerve endings destroyed. Necrosis present. Surgical intervention required for healing |
| The severity of the burn injury is related to the __________ of the burn wound. | Location |
| Lund-Browder chart | considered more accurate because the pt's age, in proportion to relative body-area size, is taken into account |
| Rule of Nines | considered adequate for initial assessment of an adult burn patient. |
| Cardiovascular complications of burn injury | Dysrhythmias and hypovolemic shock Ischemia, paresthesias, necrosis, gangrene Increase in blood viscosity Microcirculation is impaired |
| Respiratory complications of burn injury | upper airway burns cause edema formation and obstruction of the airway inhalation injury |
| Urinary complications of burn injury | Acute Tubular Necrosis blood flow to kidneys decreased, causing renal ischemia |
| Early endotracheal intubation in the burn pt | elimates the necessity for emergency tracheostomy after respiratory problems have become apparent |
| Fluid therapy for the burn pt | establish IV access that can accommodate large volumes of fluid. |
| Debridement | necrotic skin is removed |
| Open method of wound care | pt's burn is covered with a topical antimicrobial and has no dressing over the wound |
| Multiple dressing change method of wound care | sterile gauze dressing are saturated with or laid over a topical antimicrobial |
| Drug therapy for burn pts | analgesics and sedatives tetanus immunization antimicrobial agents |
| _________ takes PRIORITY over nutritional needs | Fluid replacement |
| What nutritional needs do burn pts have? | high calorie, high protein, supplemental vitamins, iron supplements |
| Emergent phase | the period of time required to resolve the immediate, life-threatening problems resulting from the burn injury |
| Acute phase | begins with mobilization of ECF and subsequent diuresis. Ends when the burned area is completely covered by skin grafts or when the wounds are healed. |
| From the onset of the burn event until the pt is stabilized, nursing and collaborative management predominately consists of airway management, fluid therapy, and wound care. | true |
| Skin health promotion includes | avoiding environmental hazards, adequate rest/exercise, proper hygiene/nutrition, use of self-examination techniques |
| Environmental hazard: sun exposure | premature aging, precancerous and cancerous lesions. Tanning is skin's response to injury. Some medications enhance the sun's effect |
| Environmental hazard: radiation | excessive radiation can cause edema, erythema, and hypo/hyperpigmentation |
| Adequate rest | sleep is restorative. NREM: body tissue restoration and repair and renewal of epithelial cells occurs |
| Exercise | increases circulation and dilates blood vessels. |
| _______ and __________ protect from bacterial overgrowth | Perspiration, skin acidity |
| Most soaps _________ skin surface | neutralize |
| Nutrition | well-balanced diet can produce healthy skin, hair, and nails. Important for skin support: vit A, B, C, K, protein, unsaturated fatty acids |
| Macule | flat, nonpalpable change in skin color, smaller than 1 cm |
| papule | Palpable, circumscribed, solid elevation in skin, smaller than 1 cm |
| Wheal | irregularly shaped, elevated area or superficial localized edema, varies in size |
| Vesicle | circumscribed elevation of skin filled with serous fluid, smaller than 1 cm |
| Pustule | Circumscribed elevation of skin similar to vesicle but filled with pus; varies in size |
| 5 characteristics of malignant skin lesions | A = asymmetry B = Border irregularity C = Color variation D = Diameter > 6 mm E = elevation |
| Malignant melanoma | a tumor occuring in melanocytes. Can spread to any organ. Most deadly skin disease. |
| Normal bacteria on the skin | staph aureus and strep b |
| Predisposing factors for infections | moisture, obesity, skin disease, systemic corticosteroids, antibiotics, chronic diseases |
| Bacterial infections of the skin | Impetigo, Furuncle, Folliculitis, Carbuncle |
| Cellulitis is characterized by | erythema, tenderness, edema |
| Viral infections of the skin | Herpes simplex (types 1/2), Herpes Zoster (shingles), Warts/plantar warts |
| Silver is | a natural antibiotic |
| Fungal infections of the skin | Candidiasis, tinea Corporis (ringworm), tinea curis (jock itch), tinea pedis (athlete's foot), tinea unguium (nails) |
| Scabies | mites under the skin |
| symptoms of scabies | severe itching at night usually not on face, on hands, wrists, genitals, axillary folds |
| treatment of scabies | launder all clothes, antibiotics if 2ndary infection, anti-itch creams |
| Begbugs | were nearly eradicated in the US 50 years ago, resistant strains of "super" bedbugs are infesting mattresses at an alarming rate. |
| Urticaria | erythema and edema from histamine response. Treat by removing the source, implementing antihistamine therapy, systemic corticosteroids, and applying cool compresses |
| Rashes from drug reactions can occur _______ days after medication. | 1-14 days |
| Lesions from contact dermatitis can appear ______ after contact with allergen | 2-7 days |
| benign conditions of the skin | acne, nevi, psoiasis, seborrheic keratoses, acrochordons, lipoma, vitiligo, lentigo |
| What are the uses of wet dressings? | to remove scales and crusts off lesions |
| What are the different types of baths? | saline, water, sodium bicarb, oatmeal |
| Surgery (definition) | the art and science of treating disease, injuries, and deformities by operation and instrumentation |
| Surgery involves... | the pt, surgeon, anesthesia care provider, and nurse |
| Purposes of surgery | Diagnosis, cure, palliation, prevention, exploration, and cosmetic improvement |
| Diagnosis: | determination of the presence and/or extent of pathology |
| Cure: | elimination or repair of pathology |
| Palliation: | alleviation of symptoms without cure |
| Prevention: | examples include removal of a mole before it becomes malignant or removal of the colon in a pt with familial polyposis to prevent cancer |
| Exploration: | surgical examination to determine the nature or extent of a disease |
| Cosmetic Improvement | examples include repairing a burn scar or changing breast shape |
| Elective surgery | carefully planned surgery |
| Emergency surgery | unexpected, urgent intervention |
| Inpatient surgery | pt is admitted to the hospital on the day of surgery. Usually pts who are in the hospital before surgery due to medical conditions |
| Ambulatory surgery is also called what? | same-day or outpatient surgery |
| What are the benefits of ambulatory surgery? | more convenient, involves fewer laboratory tests, fewer pre/post op meds, less psychological stress, less susceptibility to hospital-acquired infections, do not require an overnight hospital stay |
| Who prefers ambulatory surgery? | Physicians, third party payers, and pts |
| What kind of anesthetic is used in ambulatory surgery? | general, regional, or local anesthetic |
| What is the nurse's role in surgery? | prepare pt for surgery, care for pt during surgery, facilitate pt recovery following surgery |
| What are the primary purposes of the pt interview? | to obtain health information, to determine pt's expectation about surgery/anesthesia, to provide and clarify information about the surgical experience, to assess pt's emotional state/ readiness for surgery |
| Goal of assessment of the preop pt | to gather data in order to identify risk factors and plan care to ensure pt safety throughout the surgical experience |
| The most common psychologic factors in surgery are | anxiety, fear, and hope |
| Anxiety | Comes from facing the unknown |
| Anxiety | extremely high levels diminish cognition, decision making, and coping abilities |
| Anxiety | can arise from lack of knowledge, fear of the potential outcome, or unrealistic expectations of surgery |
| Anxiety | can arise when surgical interventions are in conflict with the pt's religious and cultural beliefs |
| Most prevalent fear | potential for death or permanent disability resulting from surgery |
| Hope | May be the pt's strongest method of coping |
| Why should a medication history be taken? | drugs and herbal products may interact with anesthetics |
| Why should a medication hx be taken? | Recreational drug use may affect the type and amount of anesthesia required. |
| Allergies | the pt with a hx of any allergic responsiveness is at a greater risk of developing hypersensitivity reactions to drugs administered during anesthesia. |
| What type of allergy should the nurse screen for? | Latex allergies |
Created by:
569961683
Popular Nursing sets