101 Exam 3-Nursing

Open Wound

When there is a break in the skin or mucous membrane (Ex. abrasions , lacerations, punctures & incisions)

Closed Wound

When there are no breaks in the skin (Ex. contusions or tissue swelling)

Acute Wound

Expected to be of short duration and can heal spontaneously without complication (Ex. surgical incision, abrasions, abscess, contusion, crushing, excoriation, laceration, penetrating, puncture, tunnel)

Chronic Wound

Exceed the expected length of recovery. Natural healing progression has been interrupted. Present for longer than 3 months (Ex. pressure injury, arterial ulcers, venous stasis ulcers, diabetic foot ulcers)

Intentional Wound

Injuries resulting from purposeful human action whether directed at oneself or others.

Unintentional Wound

Injuries resulting in an accident (Ex. cuts or falls)

Superficial Wound

Involves only the epidermal layer of the skin.

Partial-Thickness Wound

Extends through the epidermis but not through the dermis.

Full-Thickness Wound

Extend into the subcutaneous tissue and beyond (potentially to the bone)

Clean

Uninfected wounds with minimal inflammation.

Clean-Contaminated

Surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts.

Contaminated

Open traumatic wounds or surgical incisions in which a major break in asepsis occurs.

Infected

Bacteria in the wound tissues are above 100,000 organisms per gram tissue.

Abrasion

Scrape off the superficial layers of the skin. Intentional or Unintentional.

Abscess

Localized collection of pus resulting from a pathogen. Requires drainage to heal.

Contusion

Closed wound caused by blunt trauma.

Excoriation

Superficial wound, usually self-inflicted (Ex. scratches)

Crushing

Wound caused by force leading to compression or disruption of tissues.

Incision

Open, intentional wound caused by a sharp instrument.

Laceration

Skin or mucous membraned are torn open (Ex. jagged edges)

Penetrating

Open wound in which the agent causing the wound lodges in the body tissue.

Puncture

Open wound caused by a sharp object.

Tunnel

Wound with an entrance and exit site.

Arterial Ulcer

Caused by inadequate circulation of oxygenated blood to the tissue. Leads to ischemia and damage.

Venous Stasis Ulcers

Caused by incompetent venous valves, deep vein obstruction, or inadequate calf muscle function. (Ex. Venous pooling, edema, & impaired microcirculation of the skin)

Diabetic Foot Ulcer

Narrowing of the arteries leads to reduced oxygenation to the feet (Delayed wound healing and tissue necrosis)

Exudate

Drainage that oozes from a wound or cavity.

Serous Exudate

Watery consistency

Clean wounds typically have this

Straw-colored fluid that separates out of blood.

Sanguineous Exudate

Bloody drainage

Indicated damage to capillaries

Deep wounds or in highly vascular areas

Serosanguineous Exudate

A combination of bloody and serous drainage

New wounds

Purulent Exudate

Thick, & smelly drainage

Infected Wounds

Pus, bacteria, and cellular debris

Yellow but can be blue/ green with bacteria

Purosanguineous Exudate

Red-tinged pus

Small vessels in wound have ruptured

Regeneration

No scar forms

New regenerated epithelial and dermal cells form new skin

Only effects the epidermis and dermis

Primary Intention

Minimal or no tissue loss

Wound edges are are well approximated

Little scarring expected

Surgical incisions

Secondary Intention

Extensive tissue loss, which prevents wound edges from approximating

Should not be closed if there is an infection

Will likely scar

Does not have to be an open wound

Pressure sore, stitches broke open?

Tertiary intention

Occurs when two surfaces of granulation tissue are brought together

Initially uses secondary intention

When there is no evidence of edema, infection, or foreign matter, the wound edges are closed by bringing granulating tissue and suturing the surface

Inflammatory Phase

Cleansing

Hemostasis

Vessels constrict to limit blood loss and platelet clump together to slow the bleeding

Inflammatory phase

Inflammation

Phagocytosis

Migration of white blood cells into the wound tissue

Edema, erythema, pain, temperature elevation

A formed scab

In the inflammatory phase

Proliferative Phase

Granulation

Cells develop to fill the wound defect and resurface the skin

Collagen is formed-adds strength to the healing wound

New blood and lymph vessels sprout from capillaries around the wound

Maturation Phase

Epithelialization

Collagen fibers that were laid in the wound bed during proliferative phase are broken down & remodeled into an organized structure

Scar tissue

Hemorrhage

Profuse or rapid blood loss

Internal or external

Infection

Microorganisms are introduced to a wound

Smoking

Causes vasoconstriction

Dehiscence

Rupture (Separation) of one or more layers of a wound

Usually associated with abdominal wounds

“pop” or “tear” often felt by patient

Evisceration

Total separation of the layers of the wound with internal viscera

Medical emergency

Pressure Injury

Localized injury to the skin and underlying tissue usually over a bony prominence

Stage 1 Pressure Injury

Nonblanchable erythema of intact skin that lasts for greater than 30 minutes after pressure is relieved

May be painful

May be firm, soft, warmer, or cooler compared to adjacent tissue

Dark skin may seem discolored instead of red

Stage 2 Pressure Injury

Partial-thickness loss of dermis

Open but shallow & with a red/pink wound bed

No slough (tan, yellow, gray, green, or brown necrotic tissue)

May also be intact or open/ruptured serum-filled blister

Might look like a scrape, blister, “zit” or crater

Stage 3 Pressure Injury

A deep crater characterized by full-thickness skin loss

Image or necrosis of subcutaneous tissue

Adipose tissue is visible

Damage all the way down to fascia(connective tissue of body)

Does not extend through the fascia

Bone/tendon is not visible or directly palpable

Stage 4 Pressure Injury

Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures

Exposed bone, tendon, or cartilage is visible or directly palpable

Slough or eschar may be present

Depth varies by location

Can extend to muscle and supporting structures

Unstageable Pressure Injury

Involves full-thickness skin loss

The base of the wound is obscured by slough or eschar

Braden scale

Rates sensory perception, moisture, activity, mobility, nutrition, friction, & sheer

The lower the score, the more likely the patient will develop a pressure injury

Norton Scale

Based on the patient’s physical condition, mental state, activity, mobility, & incontinence

A low score indicates risk for pressure injury

PUSH (Pressure Ulcer Surface of Healing)

Reports the progression of a pressure injury

Surface area, exudate, &type of wound tissue are scored and totaled

As the injured area heals, the total score decreases

Pressure

Compresses small blood vessels, hindering blood flow and nutrient supply

Tissues become ischemic, damaged, or die

Shear

Occurs when one layer of tissue slides horizontally over another

Commonly occurs when a patient slides down in bed

Friction

When skin is moist, fragile, or dragged across a surface

Moisture

Urine, feces, & diaphoresis macerate the skin

Patient Health Status

Immobility, poor nutrition, fever, infection, dehydration, edema, impaired sensation

Manage Moisture

Incontinence care-clean after every episode

Keep skin clean & dry

Apply barrier cream

Moisturize dry skin

Massage to help with circulation

Monitor the Injury

Reassess patients often every 8-12 hours for at risk patients

Minimize Pressure

Turn & reposition

Elevate the head of bed 30 degrees or less

When side-lying, position at 30 degrees to avoid direct pressure on the trochanter

Limit time in 30 degrees or greater to prevent pressure and shear

Support Surfaces

Specialty mattresses and chair cushions they redistribute pressure

Proper Nutrition

Monitor hydration and offer water

Provide adequate calories and protein

Offer supplemental nutrition if needed

Dietary referral if needed

Patient/family teaching

Ongoing assessments

Staples & Sutures

Remove every other

Count & lay on gauze & make sure you get the same number

Approximate (bring together)

Sutures & Staples

Remove when ordered by physician

NEVER pull contaminated portion of suture through underlying tissue because of bacteria

Always clean incision before removal

Bandage

Cloth, gauze, or elastic coverings wrapped in place

Abdominal Binders

Provides support to abdomen after surgery

Decreases risk for dehiscence

T-Binder

Secures dressing or pads in perineal area

Maslow’s Hierarchy of Needs

Self-Concept

Is the frame of reference that influences how one handles life situations and relationships

Overall view of what person thinks or feels about self

Self-Perception

A filtering process that evaluates events and enters them into the subconscious

Filtering prevents feeling of guilt, anxiety, and unworthiness from surfacing

Perceives physical self & personal self-worth

Body Image

Your mental image of your physical self

Characteristics & abilities

Physical appearance & function

Gradual vs sudden body changes

Influence of body image on health

Ideal Body Image

How we would like to look

Perceived Body Image

How others objectively see your body

Actual Body Image

How the body actually looks

Role Performance

The actions a person takes and the behaviors they demonstrate in fulfilling a role

May be ascribed or assumed

Involve expectations or standards of behavior that have been accepted by society or the social group

Role strain, conflict (intrapersonal/interrole), ambiguity

Personal Identity

Your view of yourself as a unique human being different and separate from all others

Values, beliefs, personality, character, age, weight, height, sex, ethnicity

Self Esteem

How well a person likes themselves

The difference between “ideal self” & “actual self”

Sympathetic System

Responses & energy “fight or flight”

Parasympathetic System

Restoration of energy

Adrenal Glands

The inner portion (medulla) secretes

Epinephrine (adrenaline)

Norepinephrine (noradrenaline)

Stimulus-Based Model

Life events scale (also known as the Holmes & Rahe Social Readjustment Rating Scale)

Response-Based Model

Selye’s General Adaptation Syndrome (GAS)

Local Adaptation Syndrome (LAS)

Maladaptive Disorders

Stress induced psychological response: CRISIS & BURNOUT

Family

Social group whose members share values, occupy specific positions & interact with each other

Basic unit of society

Role: protect & socialize it’s members

Family Structure

Who the members of the family are and what their relationships are to one another

Family Function

What the family does

Types of Families

Traditional (nuclear) families, grandparent families, dual-earner families, military families, etc.

Challenges in Family Health

Poverty & unemployment

Infectious diseases

Chronic illness/disability

Homelessness

Violence/neglect within families

Parental Styles

Authoritarian

Permissive

Authoritative

Beliefs

Mental acceptance or conviction in truth of something

Attitudes

State of mind or feeling with regard to something

Morals

Principles of what is right and wrong

Ethics

Standards that govern proper conduct

Value

The worth of something: serves as principle or standard that influences decision making

Terminal Value

Desired goals such as happiness or career success

Instrumental Value

Desirable modes of conduct such as honesty or maintaining

Modeling

Children model their parents’ behavior along with peers & celebrities