Chapter 35 Potter & Word Scramble
|
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
Question | Answer |
________________ is the term used to describe impaired skin integrity resulting form pressure. | pressure ulcer |
A patient experiencing decreased mobility, inadequate nutrition, decreased sensory perception, or decreased activity is a risk for ________________ development. | pressure ulcer |
________________ occurs when capillary blood flow is obstructed, as in the case of pressure. | tissue ischemia |
________________ is an area of skin that appears red and warm and will turn lighter in color following fingertip palpation. | blanchable hyperemia |
________________ is redness that persists after palpation and indicates tissue damage. | nonblanchable hyperemia |
________________ is the force exerted against the skin while the skin remains stationary and the boy structures move. | shear |
________________ is an injury to the skin that has the appearance of an abrasion. | friction |
________________ on the skin increases the risk of ulcer formation. | moisture |
Poor nutrition, specifically severe ________________, causes soft tissue to become susceptible to breakdown. | protein deficiency |
Low ________________ cause edema or welling, which contributes to problems with oxygen transport and the transport of nutrients. | protein levels |
In patients with ________________, hypoalbuminemia(serum albumin level below 3 g/100 mL) leads to a shift of fluid from the extracellular fluid volume to the tissues, resulting in edema. | severe protein loss |
serum albumin level below 3 g/100 mL | hypoalbuminemia |
total protein level below 5 g/100 mL | total protein |
________________ increases the affected tissue's risk for pressure ulcer formation. | edema |
________________ is generalized ill health and malnutrition, marked by weakness and emaciation. | cachexia |
extreme thinness | emaciation |
A patient with an ________________ usually has a fever. | infection |
Infection and fever increase the ________________ of the body, making already hypoxic tissue more susceptible to ischemic injury. | metabolic needs |
Skin structure changes with ________________, causing a loss of dermal thickness and an increase in the risk of skin tears. | age |
________________ are at highest risk for development of pressure ulcers. | older adults |
60% to 90% of all pressure ulcers occur in patients over ________________ years of age. | 65 |
Pressure exerted against the skin surface causes ________________, usually a bone and the surface of the bed compress the skin. | pressure ulcers |
When the intensity of the pressure exerted to the capillary exceeds ________________, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. | 12 to 32 mm Hg |
The ulcer appears a s defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones the ulcer appears with persistent red, blue, or purple hues and the skin intact. | stage I |
Partial-thickness skin loss involving epidermis, dermis, or both; the ulcer is superficial and presents as an abrasion, blister, or shallow crater (skin is broken). | stage II |
Full-thickness skin loss involving damages to, or necrosis of, subcutaneous tissue that extends down to, but not through, underlying fascia; the ulcer presents as a deep crater with or without undermining of surrounding tissue. | stage III |
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. | stage IV |
dead, dry tissue | eschar |
A wound with little or no tissue loss, such as a clean surgical incision, heals by ________________. | primary intention |
when skin edges are close together | approximate |
A wound involving loss of tissue such as a severe laceration or a chronic wound such as a pressure ulcer heals by ________________. | secondary intention |
The wound heals with a layer of ________________ at the edges and base, and several day s after the initial wounding the wound edges are brought together with sutures or adhesive closures. | granulation tissue |
________________ are the first response to a partial-thickness wound repair, bringing white blood cells to the site. | erythema and edema |
The inflammatory response of a partial-thickness wound repair appears ________________. | red and swollen |
During the inflammatory response of a partial-thickness wound repair, the ________________, or discharge, if allowed to dry, brings the white blood cells to the area and a scab will form. | exudate |
The inflammatory response of a partial-thickness wound repair occurs for approximately ________________. | 24 hours |
Peak epithelial proliferation occurs within ________________ after injury. | 24 to 72 hours |
peak epithelial proliferation | epidermal cell migration across a wound |
Wounds kept in a moist environment will heal in approximately ________________ (as opposed to 7 days when kept dry) b/c new epithelial cells migrate across a moist surface. | 4 days |
With ________________ , the epidermis thickens, anchors to adjacent cells, and resumes normal function and looks pink, dry, and fragile. | dermal repair |
During full-thickness wound repair, the first event of ________________ is hemostasis. | inflammatory phase |
________________ cause coagulation and vasoconstriction within inflammatory phase during full-thickness wound repair. | platelets |
The ________________ during full-thickness wound repair lasts approximately 3 days in an acute clean wound, such as a surgical incision. | inflammatory phase |
The key events in the ________________ of full-thickness wound repair are production of new tissue, epithelialization, and contraction. | proliferative phase |
The ________________ of full-thickness wound repair, which lasts up to 1 year, reorganizes the collagen to produce a more elastic, stronger collagen for the scar tissue. | remodeling phase |
The tensile strength of the scar tissue during the remodeling phase of full-thickness wound repair is never more than ________________ of the tensile strength in non-wounded tissue. | 80% |
Bleeding from an acute wound is normal during and immediately after initial trauma, but ________________ usually occurs within several minutes. | hemostasis |
hemostasis | cessation of bleeding by vasoconstriction and coagulation |
collection of clotted blood | hematoma |
________________ prevents healing by increasing tissue damage and altering the healing process. | bacterial wound infection |
A contaminated or traumatic wound infection develops within ________________. | 2 to 3 days |
A surgical wound infection develops within ________________. | 4 to 5 days |
________________ of a wound infection include fever, general malaise, and an elevated white blood cell count. | systemic signs |
________________ is the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly. | dehiscence |
________________ have a high risk for dehiscence because of constant strain on their wounds and the poor vascularity of fatty tissue. | obese patients |
Dehiscence occurs most often in ________________ after a sudden strain such as coughing, vomiting, or sitting up in bed. | abdominal surgical wounds |
When ________________ drainage increases from a wound, be alert for dehiscence. | serosanguineous |
________________ occurs when wound layers separate below the fascial layer, and visceral organs protrude through the wound opening. | evisceration |
A ________________ is an abnormal opening between two organs or between an organ and the skin. | fistula |
________________ increase the risks of infection, fluid and electrolyte imbalances, and skin breakdown fro chronic drainage. | fistulas |
In the ________________, some patients require well-though-out modifications of wound care techniques. | immediate postoperative period |
Skin assessment for the patient with intact darkly pigmented skin: appears ________________ than surrounding skin--purplish, bluish, eggplant. | darker |
Skin assessment for the patient with intact darkly pigmented skin: use ________________ light versus fluorescent lamps. | natural or halogen |
Skin assessment for the patient with intact darkly pigmented skin: ________________ is taut, shiny, or indurated (edema occurs w/more than 15 mm dia.) | tissue consistency |
Skin assessment for the patient with intact darkly pigmented skin: assess for for firm or ________________ feel. | boggy |
Skin assessment for the patient with intact darkly pigmented skin: skin may feel initially ________________, but subsequently may feel ________________. | warmer; cooler |
Use ________________ such as creams, ointments, pastes, and film forming skin protectants as needed to protect and maintain intact skin. | incontinence skin barriers |
Use ________________ to transfer patients in bed. | lift sheets |
Maintain head of bed at , or below ________________ or at the lowest level of elevation consistent with the patient's medical condition. | 30 degrees |
Avoid ________________ over bony prominences. | vigorous massage |
When you notice ________________, document location, size, and color, and reassess the area after 1 hour. | hyperemia |
Turning time - arrhythmia time = | next turning time |
If you suspect ________________, outlining the affected area with a marker makes reassessment easier. | nonblancable hyperemia |
Nonblanchable hyperemia is an early indicator of ________________, but damage to the underlying tissue is sometimes more progressive. | impaired skin integrity |
________________ is associated with overall morbidity and mortality. | malnutrition |
Inadequate caloric intake causes ________________ and a decrease in subcutaneous tissue, allowing bony prominences to compress and restrict circulation. | weight loss |
The ________________ is less tolerant to pressure, friction, and shear b/c of decreased elasticity from normal aging. | older adult's skin |
The major change in aging skin is dryness, which affects as many as ________________ of patients over the age of 64. | 59% to 85% |
The thinning of the dermis and flattening of the dermal-epidermal junction that occur in aging predispose the older adult's skin to ________________. | tearing |
abrasion | loss of dermis |
An ________________ is usually superficial with little bleeding but some weeping. | abrasion |
plasma leakage from damaged capillaries | abrasion |
A ________________ is damage to the dermis and epidermis and is a torn, jagged wound. | laceration |
The depth and location of the ________________ affect the extent of bleeding, with serous bleeding possible in lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep. | laceration |
________________ bleed in relation to the depth and size of the wound. | puncture wounds |
Internal bleeding and infection are the ________________ of puncture wounds. | primary dangers |
3 steps of assessing a puncture wound: 1. inspect the wound for ________________. | contaminant material |
3 steps of assessing a puncture wound: 2. assess the ________________ of the wound and the need for suturing or surface protection. | size |
3 steps of assessing a puncture wound: 3. If from a dirty penetrating object, ascertain if patient has had a ________________ injection within the last year. | tetanus toxoid |
________________ provide an excellent environment for bacterial growth. | saturated dressing |
When you plan a dressing change, give the patient an analgesic at least ________________ before exposing a wound. | 30 minutes |
Risk for malnutrition: age: < ________________ years or > ________________ years. | 18; 64 |
Risk for malnutrition: age: weight ________________ loss in 1 to 6 month. | 5 to 10% |
Risk for malnutrition: albumin: < ________________ mg/dl | 3.0 |
Risk for malnutrition: total protein ________________ mg/dl | 5.0 |
ecchymosis | superficial bleeding under the skin or a mucous membrane; a bruise |
A simple method for estimating the volume of ________________ is to report the number and type of dressings used and saturated over an interval of time. | wound drainage |
Types of wound drainage: serous | clear, watery plasma |
Types of wound drainage: sanguineous | fresh bleeding |
Types of wound drainage: serosanguineous | pale, more watery, a combination of plasma and red cells, may be blood-streaked |
Types of wound drainage: purulent | thick, yellow, green, brown, indicating the presence of dead or living organisms and white blood cells |
Note the character and amount of drainage if there is a ________________. | collecting device |
Notify the ________________ of any sudden decrease that indicates a blocked drain or an increase indication bleeding or infection. | physician or health care provider |
When a wound exhibits swelling, separtion of its edges, or redness in the periwound area, it is important to evaluate for the presence of ________________. | cellulitis |
Use ________________ to detect localized areas of tenderness or collection of drainage. | light palpation |
Pain assessment is an important component of ________________ for detecting complications and planning for future wound care. | wound assessment |
Never collect a wound culture sample from ________________, b/c resident colonies of bacteria grow in exudate. | old drainage |
To collect an ________________, wipe a sterile swab from a culturette tube onto clean, healthy-looking tissue, return the swab to the culturette tube, cap the tube, and crush the inner ampule so that the medium for organism growth coats the swab tip. | aerobic specimen |
Nursing diagnoses relevant to wound care: risk for ________________ | infection |
Nursing diagnoses relevant to wound care: impaired ________________ | physical mobility |
Nursing diagnoses relevant to wound care: ________________ bed mobility | impaired |
Nursing diagnoses relevant to wound care: imbalanced nutrition: ________________ | less than body requirements |
Nursing diagnoses relevant to wound care: ________________ pain | acute |
Nursing diagnoses relevant to wound care: ________________ pain | chronic |
Nursing diagnoses relevant to wound care: situational low ________________ | self-esteem |
Nursing diagnoses relevant to wound care: impaired ________________ | skin integrity |
Nursing diagnoses relevant to wound care: risk for impaired ________________ | skin integrity |
Nursing diagnoses relevant to wound care: ineffective ________________ | tissue perfusion |
________________ for predicting pressure sore risk | Braden Scale |
A score of ________________ on the Braden Scale indicates at risk for pressure sores. | 16 |
A score of ________________ on the Braden Scale indicates at high risk for pressure sores. | <=9 |
Do not ________________ reddened areas b/c reddened areas indicate tissue injury. | massage |
When cleansing the skin, use a ________________ agent. | mild cleansing |
A ________________ will provide skin protection form the irritating effects of stool or urine and will allow you to clean the next incontinent episode easily. | moisture barrier |
Most underpads and briefs have a ________________ that holds moisture against skin. | plastic outer lining |
Diapers and underpads will ________________ the skin if left under patients for prolonged periods of time. | irritate |
A standard turning interval of ________________ will not prevent pressure sore development in some patients such as an immobilized patient. | 1 to 2 hours |
The WOCN recommends reducing ________________ by keeping the patient's head of bed below the 30-degree angle, using assistive devices when turning or transferring patients, using the bed gatch or footboard, and using the 30-degree lateral position. | shear |
When the patient is able to sit int he chair, reposition the patient every ________________. | hour |
Assist or teach patients with the ability to shift weight every ________________. | 15 minutes |
________________ decrease teh amount of pressure exerted over bony prominences by maximizing contact (allowing the body to touch the entire surface) and thereby redistributing weight over a large area. | support surfaces |
When using a ________________, make sure there are minimal layers of bed linens between the patient and the surface. | support surface |
Place ________________ on a pressure reduction/relief surface and not on an ordinary hospital mattress. | at-risk individuals |
Avoid using foam rings, donuts, and sheepskin for ________________. | pressure reduction |
________________ concentrate the pressure to the surrounding tissue. | foam rings and donuts |
The patient must receive ________________ to achieve wound healing. | systemic support |
________________ is necessary to support new blood vessels and collagen synthesis. | protein intake |
Certain medications and medical conditions influence ________________. | wound healing |
B/c ________________ causes problems with wound healing, blood glucose control is essential. | hyperglycemia |
A ________________ environment is necessary to promote healing. | stable wound |
To maintain a ________________ it is important to control infection and promote cleansing, debridement, exudate management, control of dead space, and wound protection. | stable environment |
Assess the patient with a ________________ for signs and symptoms of a wound infection: redness, warmth of surrounding tissue, odor, and the presence of exudate. | pressure ulcer |
Cleanse pressure ulcers at each ________________ to promote removal of wound debris and bacteria from the wound surface. | dressing change |
________________ slows wound healing b/c it becomes a source for infection and a barrier for epithelialization. | necrotic tissue |
Cleanse dirty wounds with ________________. | irrigation |
Clean wounds require only gentle flushing with ________________. | normal saline solution |
A ________________ supports wound healing. | moist wound environment |
Excessive ________________ will macerate the wound edges and interfere with wound healing. | wound moisture |
Allow a ________________ to bleed to remove dirt and other contaminants. | puncture wound |
If a ________________ is in a patient's body, do not remove the object. | penetrating object |
Gentle ________________ of a wound removes contaminants that serve a sources of infection. | cleansing |
________________ causes bleeding or further injury. | vigorous cleaning |
Ideally a ________________ provides a moist environment to promote normal epidermal cell migration. | dressing |
The proper dressing will absorb ________________ to prevent polling of exudate that promotes bacterial growth. | drainage |
The proper dressing prevents ________________ from coming into contact with intact skin. | wound drainage |
A dressing ________________ wound exposure to microorganisms. | discourages |
If a wound has minimal drainage, the natural formation of a ________________ eliminates the need for a dressing. | fibrin seal |
A pressure dressing promotes ________________ by exerting localized, downward pressure over an actual or potential bleeding site. | hemostasis |
A pressure dressing fosters ________________ by eliminating dead space in underlying tissues. | normal healing |
Assess skin color, pulses in distal extremities, patient comfort, and any changes in sensation to ensure pressure dressings do not interfere with ________________. | circulation |
A ________________ promotes healing by allowing the wound to heal by primary intention and absorbing minimal oozing of wound drainage. | dry dressing |
The purpose of a ________________ dressing is to act as a sponge, absorbing excessive wound drainage, while providing a moist environment. | moist gauze |
________________ is the most common dressing type. | gauze |
________________ does not interact with wound tissues and thus causes little wound irritation. | gauze |
________________ are useful in debriding wounds. | wet-to-dry or moist-to-dry |
The process of softening a solid by steeping in a fluid. | maceration |
________________ dressings are clear sheets coated on one side with an adhesive. | transparent film |
Transparent film dressings are used as a ________________ in wounds with minimal tissue loss that have very little wound draingage. | primary dressing |
You change a transparent film dressing when the seal is ________________. | broken |
________________ dressings are made of gelling agents and have an adhesive wound surface. | hydrocolloid |
________________ form a gel as they interact with the wound surface. | hydrocolloids |
________________ dressings are available in sheets or in a gel in a tube (amorphous). | hydrogel |
Hydrogels maintain moisture in some wounds for ________________. | 1 to 3 days |
A new treatment for chronic wounds is the wound ________________. | vacuum assisted closure |
Wound closure applies ________________ to the wound to promote and accelerate healing. | negative pressure |
add dressings w/o removing existing ones as needed | reinforce dressing prn |
An order to "reinforce dressing prn" is common immediately after ________________, when the physician or health car provider does not want accidental disruption of the suture line or loss of hemostasis. | surgery |
Use tape, ties, or bandages and cloth binders to secure a ________________ over a wound site. | dressing |
To avoid repeated removal of tape from sensitive skin, secure dressings with reusable ________________. | Montgomery ties |
Whenever cleansing a wound, clean from the ________________ contaminated area to the ________________ contaminated. | least; most |
Do not use povidone-iodine (Betadine0, hydrogen peroxide, and acetic acid (vinegar) to irrigate a ________________. They kill ________________, a key component in wound healing. | clean, granular wound; fibroblasts |
When ________________, allow the solution to flow from the least contaminated to the most contaminated area. | irrigating |
Administer the prescribed solution at ________________ to enhance comfort and provide local cleansing application. | body temperature |
When irrigating clean wounds, use sterile technique and an irrigation system with a safe pressure (________________) to prevent trauma to the newly formed granulation tissue. | 4 to 15 psi |
An example of a safe wound cleansing and irrigation system is a 35-mL syringe and a 19-gauge needle, which has a ________________. | psi of 8 |
________________ are threads or wires made of silk, steel, cotton, nylon, and polyester (Dacron) and are used to sew body tissues together. | sutures |
________________ are convenient, portable units that connect to tubular drains within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. | drainage evacuators |
Before applying a bandage or binder, perform the following steps: 1. Inspect the ________________ for abrasions, edema, discoloration, or exposed wound edges. | skin |
Before applying a bandage or binder, perform the following steps: 2. Cover exposed wounds or open abrasion with a ________________. | sterile dressing |
Before applying a bandage or binder, perform the following steps: 3. Assess the condition of ________________, and change if they are soiled. | underlying dressings |
Before applying a bandage or binder, perform following steps: 4. Assess skin of ________________ & parts that will be distal to bandage for signs of circulatory impairment to provide a means for comparing changes in circulation after bandage application. | underlying body parts |
________________ impair chest expansion. | breast binder |
The local application of ________________ to an injured body part provides therapeutic benefits. | heat and cold |
Systemic responses occur through ________________ (sweating or vasodilation) or mechanisms promoting heat conservation (vasocontriction or piloerection) and heat production (shivering). | heat loss mechanisms |
________________ generally is therapeutic. | heat |
If ________________ is applied for 1 hour or more, a reflex vasoconstriction reduces blood flow as the body attempts to control heat loss from the area. | heat |
Continuous exposure to ________________ damages epithelial cells, causing redness, localized tenderness, and even blistering of the skin. | heat |
Prolonged exposure of the skin to ________________ results in a reflex vasodilation. | cold |
Factors influencing heat & cold tolerance: 1. duration of application - a person is better able to tolerate ________________ to any temperature extremes. | short exposures |
Factors influencing heat & cold tolerance: 2. Body part - The neck, inner aspect of the wrist and forearm, and perineal regions are ________________ sensitive to temperature variations. The foot & the palm of the hand are ________________ sensitive. | more; less |
Factors influencing heat & cold tolerance: 3. Damage to body surface - Exposed skin layers are ________________ sensitive to temperature variations. | more |
Factors influencing heat & cold tolerance: 4. Prior skin temperature - The ________________ responds best to minor temperature adjustments. | body |
Factors influencing heat & cold tolerance: 5. Body surface area - A person is ________________ of temperature changes over a large area of the body. | less tolerant |
Factors influencing heat & cold tolerance: 6. Age & physical condition - The very young and old are ________________ sensitive to heat & cold. | most |
If the patient has ________________, it is unwise to apply heat to large portions of the body b/c massive vasodilation will disrupt blood supply to vital organs. | cardiovascular problems |
Cold is ________________ if the site of injury is edematous or the patient has impaired circulation or is shivering (may intensify shivering and reduce blood flow). | contraindicated |
The patient who has had rectal surgery or an episiotomy during childbirth or who has painful hemorrhoids or vaginal inflammation will benefit from a ________________, a bath in which only the pelvic area is immersed in warm fluid. | sitz bath |
heat therapy: vasodilation | improves blood flow to injury body part; example: arthritis or degenerative joint disease |
heat therapy: reduced blood viscosity | promotes delivery of nutrients and removal of wastes; example: localized joint pain or muscle strains |
heat therapy: reduced muscle tension | promotes muscle relaxation; example: menstrual cramping |
heat therapy: increased tissue metabolism | provides local warmth; example: hemorrhoidal, perianal, and vaginal inflammation |
heat therapy: increased capillary permeability | promotes movement of waste products and nutrients; example: local abscesses |
cold therapy: vasoconstriction | reduces blood flow to injured site, preventing edema formation; example: immediately after direct trauma (e.g., sprains, strains, fractures, muscle spasms) |
cold therapy: local anesthesia | reduces localized pain; example: superficial laceration or puncture wound |
cold therapy: reduced cell metabolism | reduces oxygen needs of tissues; example: minor burn |
cold therapy: increased blood viscosity | promotes blood coagulation at injury site; example: after injections |
cold therapy: decreased muscle tension | relieves pain; example: arthritis or joint trauma |
Conditions that increase risk of injury from heat and cold application: very young; older adults | thinner skin layers increase risk of burns; ________________ have reduced sensitivity to pain |
Conditions that increase risk of injury from heat and cold application: open wounds, broken skin | subcutaneous tissue is more sensitive to temperature variations |
Conditions that increase risk of injury from heat and cold application: areas of edema or scar formation | there is reduced sensation to temp. & pain stimuli b/c of scar formation |
Conditions that increase risk of injury from heat and cold application: peripheral vascular disease (e.g., diabetes, arteriosclerosis) | body's extremities are less sensitive to temp. & pain stimuli b/c of circulatory impairment & local tissue injury; cold application further compromises blood flow |
Conditions that increase risk of injury from heat and cold application: confusion or unconsciousness | there is reduced perception of sensory or painful stimuli |
Conditions that increase risk of injury from heat and cold application: spinal cord injury | alterations in nerve pathways prevent reception of sensory or painful stimuli |
high pressure over short time; low pressure over long time | same results - potential pressure ulcers |
A ________________ occurs when problems with sensory reception pr perception exist. | sensory deficit |
________________ occurs when inadequate quality or quantity of stimuli impairs perception. | sensory deprivation |
When a person receives multiple sensory stimuli, the brain has difficulty distinguishing the stimuli that causes a ________________ to occur. | sensory overload |
a common progressive hearing disorder in older adults | presbycusis |
gradual decline in ability of the lens to accommodate or to focus on close objects; reduces ability to see near objects clearly | presbyopia |
examples of medications reported to cause ototoxicity | antibiotics, diuretics, analgesics/NSAIDs, antineoplastic agents |
gustatory | taste |
proprioception | position and movement in space |
olfactory | smell |
Created by:
chaptravelman
Popular Nursing sets