Other System
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| Penetrating wounds | A wound that enters the interior of an organ or cavity
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| Arterial Insufficiency Ulcers recommendations | Avoid unnecessary leg elevation, avoid using heating pad or soaking feet in hot water
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| Venous insufficiency Ulcers recommendations | Compression to control edema
Elevate legs above the heart
Attempt active exercise include ROM
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| 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
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| 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
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| 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
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| Partial-thickness wound | Extends through the epidermis and possible into, but not through the dermis
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| Full-thickness wound | Extends through the dermis into deeper structures such as subcutaneous fat
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| Subcutaneous Wound | Subcutaneous wounds extend through integumentary tissues and involve deeper structures such as subcutaneous fat, muscle, tendon, or bone
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| Seropurulent | Presents as cloudy or opaque, with a yellow or tan color and a thin, water consistency
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| Purulent | Presents with a yellow or green and a thick, viscous consistency.
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| Hyperkeratosis | Referred to as a callus, is typically white/gray in color and can vary in texture from firm to soggy
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| Ecchymosis | The discoloration occurring below intact skin resulting from traum to underlying blood vessels and blood seeping into tissues. Referred to as a bruise
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| Normotrophic Scar | A scar characterized by the organized formation of collagen fiber that align in a parallel fashion
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| Turgor | The relative speed with which the skin resumes its normal appearance after being pinched
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| Superficial partial-thickness Burn | Involves the epidermis, and the upper portion of the dermis, may be extremely painful and exhibit blisters
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| 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
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| 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
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| Subdermal Burns | The complete destruction of the epidermis, dermis, and subcutaneous tissue. May involve muscle and bone tissue
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| Rules of nines - head and neck | 9
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| Rules of nines - anterior trunk? Posterior trunk? | 18 and 18
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| Rules of nines - Bilateral anterior arm, forearm, and hand? Posterior? | 9 and 9
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| Genital region | 1
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| Rules of nines - Bilateral anterior leg and foot? posterior? | 18 and 18
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| How much pressure is needed to create an environemt that facilaties the balance of collagen synthesis and lysis | 15-35 mm Hg
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| Cellulitis | Results from a bacterial infection
-localized redness, warm or hot skin, local abscess or ulceration, tenderness to palpation, chills, fever, malaise
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| Contact Dermatitis | A superficial irritation of the skin from localized irritation
-intense itching, burning, red skin, local edema
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| 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
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| 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
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| 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
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| Plaque Psoriasis | Chronic autoimmune disease
-raised red blotches that present in a bilateral fashion. Itchy and flaky
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| Metabolic Alkalosis | An increase bicarbonate or loss of acid
Nausea, diarrhea, confusion, muscle fasciculations, cramping, convulsions, and hypoventilation
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| Metabolic Acidosis | Accumulation of acids; assoc. renal failure, diabetic or alcoholic ketoacidosis
-hyperventilation, vomiting, diarrhea, headache, weakness, and malaise, cardiac arrhythmias
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| Addison's Disease | Hypofunction of the adrenal Cortex
-Hypotension, weakness, anorexia, weight loss, altered pigmentation
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| 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
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| Hypothyroidism | fatigue, weakness, decreased heart rate, weight gain, constipation, delayed puberty, and retarded growth and development
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| Hyperthyroidism | Increased nervousness, excessive sweating, weight loss, increase in blood pressure, exophthalmos, myopathy, chronic periarthritis, and an enlarged thyroid gland
-Graves disease
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