lab quiz 7 Flashcards
(42 cards)
1
Q
skin changes with age
A
- Elasticity and collagen are reduced
- Underlying muscles and tissues are thinned
- Comorbid conditions
- polypharmacy
- reduced inflammatory response
2
Q
pressure injuries
A
- Form due to pressure intensity (tissue ischemia, blanching), pressure duration, and tissue intolerance
- This leads to economic consequences when ineffectively prevented or treated in healthcare facilities
- Occur over bony prominences
3
Q
stage 1
A
non-blanchable erythema of intact skin
4
Q
stage 2
A
partial-thickness skin loss with exposed dermis
5
Q
stage 3
A
Full-thickness skin loss
6
Q
stage 4
A
full-thickness skin and tissue loss
7
Q
deep tissue
A
purple or maroon, non-blanching and boggy
8
Q
unstageable
A
full-thickness tissue loss and eschar/slough with necrotic tissue
9
Q
stages of partial-thickness wound repair
A
- inflammatory
- proliferative
- maturation
10
Q
stages of full-thickness wound repair
A
- hemostasis
- inflammatory
- proliferative
- maturation
11
Q
primary intention
A
- incision with a blood clot
- sutures
- fine scar
12
Q
secondary intention
A
- irregular large wound
- epithelial cells and sutures
- large scar
13
Q
tertiary intention
A
- contaminated wound
- increased granulation
- late suturing with large scar
14
Q
Complications of wound healing
A
- Hemorrhage: excessive bleeding (internal or external)
- Infection: erythema, purulent drainage
- Dehiscence: reopening of a wound closure
- Evisceration: internal organs are on the outside (cover with sterile gauze)
15
Q
wound prevention
A
- Assess patients at risk using the Braden scale
- Intervene when applicable and indicated
16
Q
wound risk factors
A
- Impaired sensory perception, perfusion, or mobility
- Altered LOC
- Shear and friction
- Moisture
- Nutrition
- Age or underlying conditions
17
Q
Risk for breakdown (Braden scale)
A
- Sensation
- Mobility
- Continence
- Wound presence
- Wound history
- Skin integrity
- medical/assistive devices
18
Q
assessing wound appearance
A
- Location and type
- Extent of tissue damage
- Type of tissue in the wound base
- Edge of wound characteristics
- Size and approximation
- Drainage (amount and characteristics)
- Inflammation and discoloration
- Pain
- Odor
19
Q
Interventions for health promotion
A
- Nutrition and fluid intake
- Pressure redistribution
- Incontinence care
- Repositioning and mobility
- Use of mobility devices
20
Q
Purpose of wound dressings
A
- Protect the wound from microorganisms and contamination
- Aid in hemostasis
- Promote healing through absorption and debridement
- Support or splint wound site
21
Q
wound dressing considerations
A
- Can it be changed or reinforced
- Can clean or sterile technique be used
- How is the dressing secured
- How are the materials disposed of
- Who will be changing the dressings at home
22
Q
removing old dressings
A
- Assess the patient’s pain
- Prepare for procedure, apply PPE
- Remove adhesive, and remove old dressing one layer at a time. Observe all drainage
- Dispose of gloves and soiled dressing
- Assess and palpate wound
23
Q
securing dressings
A
- Rolled gauze
- tape
- abdominal binder
- adhesive ties
- tubigrip
24
Q
Debridement
A
- removal of dead tissue to promote the healing of healthy tissues
- Types: mechanical, autolytic, chemical/enzymatic, biological, sharp/surgical
25
drain removal
- Assess pain
- Remove drain suction, remove sutures and staples
- Instruct the patient to take deep breaths, stabilize the surrounding skin with a gauze pad, and swiftly/evenly withdraw the drain
- Inspect drain components to make sure it is fully intact
26
insulin
allows glucose to enter cells, secreted from the pancreas
27
glucose
source of energy for cells that make up muscles and other tissues, sourced from food and liver
28
diabetes mellitus
- Type 1: no insulin is produced
- Type II: insulin resistance
29
Fasting plasma glucose
- Pre-diabetes - 100-125
- Type I or II - > 126
30
Oral glucose tolerance
- Pre-diabetes - 140-199
- Type I or II - > 200
31
diabetes s/s
- Increased hunger and thirst
- Frequency
- Unexplained weight loss
- Irritability and mood changes
32
type I risk factors
family history, genetics, geography, age
33
type II risk factors
overweight, obesity, inactivity, family history, race/ethnicity, blood lipid levels, age, pre-diabetes/gestational diabetes
34
pre-diabetes risk factors
- Overweight, obese, large waist size
- Poor diet or inactivity
- Age
- Family history
- Race and ethnicity
- Gestational diabetes
- Polycystic ovary syndrome
- Obstructive sleep apnea
- Smoking
35
Gestational diabetes risk factors
- Overweight or obese
- Inactivity
- Large birth weight
- Social determinants of health
- Race or ethnicity
36
rapid-acting insulin
types - aspart, lispro, glulisine
onset - 15 mins
peak - 1-3 hours
duration - 3-5 hours
37
short-acting insulin
types - regular or human
onset - 30 mins
peak - 2-4 hours
duration - 5-8 hours
38
intermediate-acting insulin
types - NPH
onset - 15 mins - 4 hrs
peak - 14-12 hours
duration - 16-24 hours
39
long-acting insulin
types - glargine, detemir, degludec
onset - 1-2 hours
peak - 6-12 hours
duration - 24 hours
40
Complications of insulin use
- Hypoglycemia
- hyperglycemia
- insulin resistance
- dawn phenomenon
- Somogyi effect
41
Insulin storage and safety
Store in fridge, keep out of direct sunlight, check expiration date, examine vials
42
Syringe storage and safety
Cleanse skin before administering
Do not reuse or share
Keep needles clean
