Term
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Definition
- Protection - Temperature REgulation - Psychosocial - Sensation - Vitamin D production - Immunological - Absorption - Elimination |
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Term
Factors affecting skin integrity |
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Definition
Developmental Considerations - younger than 1 thin skin - older skin integrity
STate of health - - thin and obese subject to skin - Fluid loss through fever, vomit or diarrhea reduces the fluid volume of the body - Excessiver perspiration - Jaundice - Disease of the skin - Diabetes slow healing - |
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Term
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Definition
- Incision - Contusion - Abrasion - Laceration - Puncture - Avulsion - tearing a structure from normal anatomic position possible damage to blood vesels - Microbial - secretion of exotoxins or endotoxins - Chemical - Thermal - Irridation - Pressure Ulcer - Venous Ulcer - injury to poor venous return from underlying conditions such as incompetent valve and obstruction - ARterial ulcer - injury and underlying ischemia resulting from underlying conditions - Diabetic Ilcers - |
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Term
Classifications of Wounds |
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Definition
Intentional and Unintetional Open and Closed Acute and Chronic |
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Term
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Definition
Hemostasis - clotting platelets, exudate - liquid cut Inflammatory Phase - lukocytes and macrophages Proliferation Phase - connective tissue phase Maturation phase - collagen remodeling - scar |
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Term
Factors affecting wound healing |
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Definition
dessiccation - (dehydration) maceration (overhydration) necrosis (death of a tissue)
Local factors Pressure, dessication, maceration, trauma, edema, infection, necrosis
Systemic factors - age, circulation and oxygen, nutritional status, wound condition, meds and health statuse, immunosuppresion
Other complications Infection Hemorrhage Dehiscence - total separation of wound layers Evisceration - complete separation Fistula - abnormal passage from an internal organ to the outside of the body, or from one organ to another - often a result of infectionl |
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Term
Factors in Pressure Ulcers |
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Definition
External pressure Friction and Shear |
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Term
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Definition
Immobility Nutrition and Hydration Moisture Incontinence Skin Hygiene Diabetes Mellitus Diminished Pain Awareness Fracture History of Corticosteroid itherapy Immunosuppression Multisystem TRauma Poor circulation PRevious Pressure Ilcer Significant OBseity or Thinees |
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Term
STages of Pressure UIcers |
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Definition
Stage 1 - Red skin over bony prominence Stage 2 - Partial thickness loss of dermis, pink wound without slough shiny or shallow. Present as intact or open blister Stage 3 - Full thickness tissue loss or directly palpable. Slough may be present but doesn't obscure may involve tunneling. stage 4 - tissue loss with exposed bone tendon or muscle is visible. Exchar or slough may be present may have tunneling Unstagageabe- bottom of lucer covered by slough and eschar in wound bed. |
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Term
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Definition
Sensory Perceptoin - completely limited, very limited, slightly limited Moisture - const moist, very moist, occ moist, rarely moist Activity - bedfast, chairfast, walks occ, walks freq Mobility - commpletely immobile, very limited, slightly limitied, no limitation nutrition - very poor, probalby inadequate, adequate, excellent friction and sheer - problem, pot prob, no apparent prob |
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Term
Nutritional risk for ulcer |
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Definition
Albumin <3.2 (normal 3.5 - 5 Prealbumin - <19 normal is 16-40 body weight > 15%
total lymp count <1800 norm is 1000 - 40000 hemo A1C> 8% normal <6% glucose > 120 mg norm 70-120 |
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Term
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Definition
Red = protect Yellow = cleanse Black = Debride |
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Term
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Definition
Serous drainage - composed of primarily of clear serous portion of the blood from serous membrane- clear and watery
Sanguineous drainage - llarge number of red blood cells - bright red is fresh bleeding where as dark is older blood
Serosanguineous drainage - mix of the first two pink to blood
Purulent drainage - white blood cell, liquified tissue debris and dead and alive bacteria. musty color |
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Term
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Definition
Penrose -provides sinus tract - after incision and drainage of abscess in abd surgery T Tube - for bile drainage - after gallbladder surgery Jackson Pratt - decrease dead space by collecting drainage - after breast removal ab surgery Hemovac - decrease deead space by collecting drainage - after abdominal ortho surgery Gauze - allow healing from base of wound - infected wounds after removal of hemorrhoids |
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Term
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Definition
Disturbed body Image Deficient Knowlege related to Wound Care Acute Pain Chronic Pain Impaired Tissue Integrity REadiness for Enhanced Knowledge Impaired Skin Integrity Activity Intolerance Self Care Deficit Risk for Impaired Skin Integrity Risk for Trauma |
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Term
Nursing Wounds Outcome Identirication and Planning |
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Definition
Maintain skin integrity Demonstrate self care measures to prevent pressure ulcer development
Demonstrate self care measures to promote wound healing Demonstrate evidence of wound healing Demonstrate increase in body weight and muscle size if appropriate REmian free of infection at the site of the wound or pressure ulcer Remain free of sings and symptoms of infection Verbalize the pain managent regime relieves pain to an acceptable level Be discharged to home within established parameters Demonstarte appropriate wound care measures before discharge Verablize understanding of signs and symptoms |
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Term
Nursing Wounds Interventions |
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Definition
Bedrest Care Incision Site Care Woudn Care Pressure Management Pressure Ulcer Prevention Skin Surveliance |
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Term
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Definition
removal of devitalized tissue |
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Term
Types of dressings/products |
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Definition
Tramsparent films - allow O2 exchange, self adhesive, waterproof protect against contamination, maintain moist environment, allow visualization of wound,
Hydrocolloid dressing - occlusive or semiocclusive - limiting exchange of oxygen between wound and environment. Minimal to moderate absorption of drainage maintain wound environment, moist environment, provide cushion, protect against contamination, may be left in place for 3 to 7 days
Hyudrogels - maintain a moist wound environment, minimal absorption of drainage, facilitate auolytic debridement, do not adhere to wound reduce pain most require a secondary dressing to secure
Alginates - absorb exudate, maintain a moist wound environment, facilitate autolytic debridement, requires secondary dressing, can be left in place for 1 to 3 days
Foams - maintain moist wound environment, do not adhere to wound, insulatee wound, highly absorbent, can be left in place 7 days
Antimicrobials - refudce infection and prevent infection
Collagens - maintain a moist wound environment, do not adhere to wound, not compatible with topical agents, non adherent,
Composites - combine two omre more physically distinct products in a single dressing. Allow exchagne of oxygen between wound and environment may facilitate autolytic debridement provide physical bacterial barrier and absorptive layer. semiadherenet |
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Term
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Definition
heat and cold are applied to a specific part or all of patients body for local or systemic change
heat - dilates vessels, increases tissue metabollism, reduces blood viscosisty and increases capillary permeability, reduces muscle tension, and reileves pain.
cold - constricts bvessels, reduces muscle spasms, promotes comfort, decreases formatoin of edema, and ddecreases local release of pain producing subsmtances. controls bleeding.
heat 20 - 30 mins only as after that time vasoconstirction occurs. cold 15C or 60F vasodilation begins. |
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Term
Nursing Dx Hot cold Therapy |
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Definition
Ineffective thermoregulation ineffective tissue perfusion actue pain chronic pain risk for injury risk for trauma |
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Term
Nursing Outcome Hot Cold Therapy |
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Definition
Verbalize increased comfort Demonstrate evidence of wound healing decreased muscle spasm decreased edema increased comfort Verbalize and demonstrate safe hot or cold application |
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Term
Nursing Intervention Hot cold therapy |
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Definition
Heat Dry Heat - Hot water Bags, Electric HEaing Pad, Aquathermia PAd, Hot Packs,
Moist Heat - warm compress, sitz bath, warm soak
Cold Dry Cold - ice bag, Cold Pack Moist Cold - cold compress |
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Term
Nursing Evaluation Hot Cold THerapy |
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Definition
Verablize increased comfort Verbalize increased ability to sleep and rest Demonstrate evidence of wound healing Demonstrate a decrease in symptom of muscle spasm inflammation and dedema |
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