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Flashcards in Week Eleven Deck (370)
1

What are the body's non-specific defense mechanisms that protect against infection?

Intact Skin/Mucous membranes, Inflammatory Response

2

Phagocytosis

The process by which cell engulf microorganisms and cellular debris.

3

What is the Inflammatory Response?

A local and non-specifc defensive agent that occurs once the external barriers are compromised. It occurs the same way every time. It is an adaptive mechanism.

4

What are the three things that the Inflammatory Response does?

Destroys or dilutes the injurious agent, prevents further spread of the injury, promotes the repair of damaged tissues

5

What assessment findings indicate inflammation?

Pain, Swelling, Redness, Heat, Impaired function of the part if the injury is severe

6

What are the causes of Inflammation?

Physical Agents, Chemical Agents, Microorganisms

7

What is meant by physical agents as a cause for inflammation?

mechanical objects causing trauma to tissue, excessive heat or cold and radiation

8

What is meant by chemical agents as a cause for inflammation?

Includes internal irritants and external irritants

9

What is meant by microorganisms as a cause for inflammation?

Bacteria, viruses, fungi, and parasites

10

What are the three stages of inflammation?

Stage One: Vascular and Cellular Response, Stage Two: Exudate Production, Stage Three: Repair

11

Stage One: Vascular and Cellular Response

short period of vasoconstriction at the site of injury ---> rapid vasodilation ---> marked increase in blood supply (hyperemia) ---> REDNESS AND HEAT --> Increase in vascular permeability ---> Fluids, proteins, and leukocytes move into the interstitial spaces --> SWELLING & PAIN --> Leukocytosis

12

What observations would you find in an assessment with a person in stage on of the inflammatory response?

Redness and Heat due to vasodilation, Swelling and pain due to altered vascular permeability that causes an outpouring of fluid, proteins, and leukocytes into the interstitial spaces

13

What is vasoconstriction?

Constriction of blood vessels (smaller)

14

What is vasodilation?

Dilation of small blood vessels (bigger)

15

What is hyperemia?

A marked increase in blood supply

16

What are the concerns regarding inflammation (stage one)?

Too much fluid pouring into areas such as the pleural or pericardial cavity can seriously affect organ function

17

What is leukocytosis?

Blood flow slows in the dilated vessels. This altered rate of flow helps in moving more leukocytes to the injured tissues. In response to the exit of leukocytes from the blood vessels, the bone marrow produces large numbers of leukocytes and releases them into the blood stream called leukocytosis.

18

Serous

clear, watery plasma

19

Serosanguineous

consists of clear and blood tinged drainage that is commonly seen in surgical incisions

20

Sanguineous

Large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow escape of RBCs from plasma. Seen in open wounds

21

Stage Two: Exudate Production

Fluid, dead phagocytic cells, dead tissue cells --> "exudate"

22

Purulent

Thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria varying in color including blue, green or yellow. Color depends on the causative organism.

23

Which type of exudate would you not wish to find in a clinical assessment?

purulent

24

Stage Three: Repair

Involved the repair of injured tissue by regeneration or replacement with fibrous tissue (scar) formation.

25

Regeneration

The replacement of destroyed tissue cells by cells that are identical or similar in structure and function

26

Granulation Tissue

Young connective tissue with new capillaries formed during the wound healing process

27

Fibrous Tissue

Scar tissue

28

What is the Immune Response?

Body's 3rd, slowest line of defense. Directed against identifiable bacteria, viruses, fungi, or other infectious agents.

29

What is Immunity?

The specific resistance of the body to infectious agents.

30

What initiates the immune response?

antigens

31

What are antigens?

foreign "things" to the body

32

What happens in response to the presence of antigens?

The body begins to produce antibodies

33

What do antibodies do?

Neutralize toxins and assist in destroying bacteria

34

What is Humoral Immunity?

Aquired Immunity. B lymphocytes. Mediated by the antibodies produced by B cells. Can be active/passive and natural/artifical

35

What are B Cells?

B cells are specific to one antigen. B cells produce antibodies to the antigen causing humoral immunity which protects the body against infection.

36

What is Active Immunity?

Antibodies are produced by the body in response to an antigen

37

What is Natural Active Immunity?

Lifelong. Antibodies are formed in the presence of active infection in the body.

38

What is Artificial ACtive Immunity?

Boosters must take place to reinforce immunity. Antibodies are administered to stimulate antibody production.

39

What is Passive Immunity?

Antibodies are produced by another source...animal or human.

40

What is Natural Passive Immunity?

Six Months- 1 year protection. Infant receives from mother.

41

What is Artificial Passive Immunity?

2-3 week protection. Immune serum (antibody) from an animal or other human in injected

42

What is another name from cell mediated defenses?

cellular immunity

43

What type of cells are involved in cell mediated defenses (cellular immunity)?

T Cells

44

What is Cell Mediated Defenses?

On exposure to an antigen, the lumph tissues release large numbers of activated T cells into the lymph system. When this immunity is lost, the individual is "defenseless" against most infections

45

What are the three main groups of T Cells?

Helper T Cells, Cytotoxic T cells, Suppressor T cells

46

What do Helper T Cells do?

Help in function of immune system

47

What do cytotoxic T cells do?

Attack and kill microorganisms and sometimes the body's own cells.

48

What do Suppressor T Cells Do?

Suppress the functions of the T cells and cytotoxic T Cells.

49

What do both T and B cells create?

Memory cells that remember an antigen and attack if the antigen invades again.

50

What are the body's non-specific defenses that protect against infection?

skin, mucous membranes, inflammation

51

What are the body's specific defenses that protect against infection?

immune response

52

What is an infection?

An invasion of body tissues by microorganisms and their growth there

53

What is the difference between inflammation and infection?

Inflammation is the local and nonspecific defensive tissue response to injurious or infectious agents; it is an adaptive mechanism that destroys or dilutes the injurious agent, prevents further spread of injury, and promotes the repair of damaged tissues. Infection is the invasion and growth of microorganisms on body tissues.

54

What are the factors that increase an individual's susceptibility to infection?

Age, Heredity, Stress, Nutrition, Medical Therapies or Diseases, and Medications

55

How does Age play a role in an individual's susceptibility to infection?

Newborns and older adults have reduced defenses against infection

56

How does Heredity play a role in an individual's susceptibility to infection?

Influences the development of infection in that some people have a genetic susceptibility to certain infections

57

How does Stress play a role in an individual's susceptibility to infection?

Elevates blood cortisone. Prolonged elevation of blood cortisone decreases anti-inflammatory responses, depletes energy sources, leads to state of exhaustion and decreases resistance to infection

58

How does Nutrition play a role in an individual's susceptibility to infection?

Resistance to infection depends on adequate nutrition

59

Which medications play a role in an individual's susceptibility to infection?

antineoplastic, antiinflammatory, antibiotics

60

Abrasion

Open wound involving the skin. Surface scrape, either unintentional, such as a scraped knee from a fall or intentional, such as dermal abrasion to remove pockmarks.

61

Contusion

Closed wound - skin appears ecchymotic. Caused by a blow from a blunt instrument.

62

Incision

Open wound - deep or shallow Caused by sharp instrument such as knife or scalpel.

63

Laceration

Open wound; edges are often jagged. Tissues torn apart, often from accidents, such as with machinery.

64

Puncture

Open wound. Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional

65

Define Infection, Risk For

At risk for being invaded by pathogenic organisms.

66

Risk factors for Infection, Risk For

invasive procedures, insufficient knowledge regarding avoidance of exposure to pathogens, trauma, tissue destruction and increased environmental exposure, rupture of emniotic membranes, pharmaceutical agents, malnutrition, increased environmental exposure to pathogens, immunosuppression, inadequate acquired immunity, inadequate secondary defenses, inadequate primary defenses, chronic disease

67

Serum White Blood Cell Count Normal Adult

5,000-9,000 cubic millimeters

68

Increased Serum White Blood Cell Count

Sign of Leukocytosis & Infection. Over 9,000 cubic millimeters.

69

Decreased Serum White Blood Cell Count

Sign of Autoimmune Disease, Leukopenia. Below 5,000 cubic millimeters.

70

Leukopenia

A reduction in the number of white blood cells in the blood, typical of various diseases.

71

What does the differential count consist of?

neutrophils, lymphocytes, monocytes, eosinophils, and basophils

72

What are Neutrophils?

The largest group, first line of defense against invading organisms. Quickly die and form exudate or pus in inflammatory response

73

What is the lifespan of Neutrophils?

6-12 hours.

74

Normal Neutrophil Findings For Adult

50-70%

75

Increased Neutrophil Finding

Sign of Stress and/or Acute Infection

76

Decreased Neutrophil Finding

Sign of Viral Disease and/or Radiation Therapy

77

What are Lymphocytes?

Differentiate invading cells from normal cells, travel to injured site and initiate immune response

78

Normal Lymphocyte Findings For Adults

25-45%

79

Increased Lymphocyte Finding

Sign of: chronic bacterial infection, mononucleosis, tuberculosis, viral infection, lymphocytic leukemia

80

Decreased Lymphocyte Finding

Sign of: immune suppressive medications, autoimmune diseases, severe malnutrition

81

What are Monocytes?

Ingest dead or defective cells, migration out of the bone marrow in response to infection or inflammation, primary cells involved in beginning stages of inflammation, initiate process that allows T cells and B cells to recognize antigens (foreign agents)

82

Normal Monocyte Findings For Adults

4-6%

83

Increased Monocyte Findings

Sign of: chronic inflammatory disorders, tuberculosis, chronic ulcerative colitis, protozoan infections

84

Decreased Monocyte Findings

Sign of: Medication Therapy (prednisone)

85

What are Eosinophils?

Travel to injured site that are a result of an allergic reaction

86

Normal Eosinophil Findings Adult

1-3%

87

Increased Eosinophil Findings

Sign of: Parasitic infections, Allergic infections, Leukemia

88

Decreased Eosinophil Findings

Sign of Corticosteroid therapy

89

What are Basophils?

Aid in inflammatory process by producing histamine

90

Normal Basophil Findings Adult

0.4-1%

91

Increased Basophil Findings

Leukemia

92

Decreased Basophil Findings

Sign of: Acute allergic reaction, acute infections, corticosteroids

93

Where are cultures obtained from?

Body Fluids

94

Why are cultures obtained from body fluids?

To isolate the source of unknown fevers and to identify the microorganism causing signs of clinical infection

95

Which body fluids are culture specimens obtained from?

blood, sputum, stool, throat, wound exudates, urine, spinal, joint, pleural or other body cavity fluids

96

What is a benefit of obtaining good culture specimens?

sensitivity testing of microorganisms

97

What is sensitivity testing?

After microorganisms are grown in culture media, various concentrations of antibiotics are used to test their ability to inhibit growth or kill the organism. The laboratory reports the names of the organisms present and whether they are sensitive or resistant to specific antibiotics.

98

Where are blood cultures obtained from?

Two separate venipuncture sites.

99

When is the ideal blood specimen drawn?

Just before or during the rise in temperature

100

What equipment do you need to obtain a blood specimen?

a set of culture bottles, a sterile syringe, two sterile needles, skin preparation equipment and a tourniquet.

101

Now Let Me Evaluate Blood

N: Neutrophils quickly die and form exudate L: Leukocytes initiate immune response M: Monocytes are the primary cells at the start of inflammation E: Eosinophils go to the injury site as a result of an allergic reaction B: Basophils aid inflammatory response by releasing histamine

102

Why would a sputum culture be obtained?

When a client has a fever and productive cough.

103

When should a sputum culture be obtained?

In the morning before the client eats because it should not contain saliva because it contaminates the specimen.

104

Why is blood not drawn from previously inserted lines?

Because indwelling catheters may be contaminated with surgace pathogens.

105

Why is the blood culture specimen drawn just before or during a rise in temperature?

Because the pathogens are usually circulating in high concentration at that time

106

How do you obtain a throat culture?

With a sterile cotton swab that is touched to the back of the throat as the client says ahhh

107

Why is it important to perform a throat culture procedure quickly?

it may trigger the gag reflex

108

What is important to due after obtaining a throat culture?

Maintain sterility, place the swab into a culture medium and transport to the lab.

109

What is the purpose of obtaining a urine culture?

To determine the presence of microorganims and the antibiotics to which the organisms are sensitive.

110

What are the purposes for obtaining a wound culture?

To identify the microorganisms potentially causing an infection and the antibiotics to which they are sensitive and to evaluate the effectiveness of antibiotic therapy

111

What is the first thing you must do when preparing to obtain a wound culture?

Assess the appearance of the wound and surrounding tissue. Check the character and amount of wound drainage.

112

What is the second thing you should do when preparing to obtain a wound culture?

Assess client complaints of pain or discomfort at the wound site

113

What is the third thing you should do when preparing to obtain a wound culture?

Assess signs of infection such as fever, chills, or elevated white blood cell count

114

Why must you assess the wound, client symptoms, and signs before obtaining a wound culture?

To gather data regarding the progression of wound healing and note any signs or symptoms of infection, to be documented and reported to primary care provider.

115

Where should you take a sample for a wound culture?

areas of granulation tissue because the microorganisms most responsible for the wound infection reside in viable tissue.

116

What must you determine before obtaining a specimen for a wound culture?

If the wound should be cleaned prior to obtaining specimen, whether the site from which to take the specimen has been specified

117

What should you not use when obtaining a specimen for a wound culture?

Pooled exudate or pus. These secretions contain a mixture of contaminants that are not the same bacteria as those causing the infection.

118

What equipment do you need to gather in preparing to take a specimen for a wound culture?

PPE, googles, gown, clean gloves, sterile gloves, moisture proof bag, sterile dressing set, normal saline and irrigating syringe, culture tube with swab and culture, medium and/or sterile syringe with needle for anaerobic cultures, completed labels for culture containers, completed requisition to accompany the specimens to the laboratory

119

Where are aerobic organisms found?

surface of the wound

120

Where are anaerobic organisms found?

deep in wounds, tunnels, or cavities

121

Why must you check the medical orders before obtaining a specimen for wound culture?

cultures need to be ordered by the PCP and a lab requisition needs to be signed by the PCP to accompany the culture to the lab

122

What should you administer for pain 30 minutes before a wound culture procedure?

analgesic PRN for pain during treatment

123

Where should you discard the old dressing after removing it in a wound culture specimen collection procedure?

In a moisture-proof bag, making sure it does not touch the outside of the bag

124

When should you don sterile gloves in a wound culture specimen collection procedure?

After you have opened your sterile dressing set using sterile technique and assessed the wound

125

What should you assess before donning sterile gloves in preparing for obtaining a specimen for wound culture?

swelling, opening at the edges, inflammation, bleeding, and drainage. Palpate along the wound edges noting any tenderness or drainage.

126

What solution should you use when cleaning the wound for obtaining a specimen for a wound culture?

normal saline because the use of antiseptic solution may destroy the organisms present and result in a false negative culture report

127

Where should you avoid touching when swabbing for a wound culture?

intact skin at wound edges

128

When should the specimen for a wound culture be delivered to the lab?

Within 15 minutes

129

What is the best way to decrease the inflammatory response?

The prevention of infection, trauma, surgery, and contact with potentially harmful agents.

130

What two vitamins are important for healing?

Vitamin A & C

131

Why are vital signs important to note with inflammation?

When an infectious process is present, T, P, & R may increase.

132

Why is it important to elevate an injured site?

It will reduce edema at the inflammatory site and increase venous return. Elevation helps reduce pain and improve circulation of blood which provides the oxygen and nutrients needed for healing

133

Why is it important to teach a client with inflammation about stress reduction techniques?

Excessive stress predisposes individuals to infections

134

Why is it important to monitor and document fluid intake and output every shift for those with inflammation?

Fluid intake permits fluid output that flushes out the bladder and urethra, removing microorganisms that could cause an infection.

135

Why is it important to assess and educate a client on the importance of rest and sleep that has inflammation?

Essential to health and renewing energy. Rest and immobilization of the inflamed area promote healing by decreasing the inflammatory process, assisting in the repair process and decreasing metabolic needs

136

Why is it important to assess the client's past immunizations on admission and follow recommended immunization schedule throughout the life span and obtain PCP orders to administer required immunizations with clients with inflammation?

Immunizations have dramatically decreased the incidence of infectious diseases

137

Why is it important to maintain supple, moist skin in those with inflammation?

Dry skin can lead to inflammation, excoriations and possible infection.

138

What are antibiotics?

an antimicrobial agent derived from cultures of a microorganism or produced semi synthetically, used to treat infections

139

What are antimicrobials?

An agent that kills or inhibits the growth or replication of microorganisms

140

Ampicillin TRADE NAME

Polycillin or Omnipen

141

Polycillin GENERIC NAME

Ampicillin

142

Omnipen GENERIC NAME

Ampicillin

143

What is the action of Ampicillin?

Interferes with cell wall replication of susceptible organisms. The cell wall, rendered osmotically unstable, swells and bursts from osmotic pressure.

144

What are the Side/Adverse effects of Amipicillin

Coma, Seizures, N, V, D, Glomerulonephritis, Bone marrow depression, Granulocytopenia, Pseudo membranous colitis, Anaphylaxis, Vaginitis, Rash

145

What are the nursing implications for po administration of AMPICILLIN?

administer on empty stomach for best absorption 1-2 hours before meals or 2-3 hours after meals, store in dry, tight, container, oral suspension refrigerated for two weeks or one week at room temp, tablets can be crushed, capsules may be opened and mixed with water

146

For best absorption, how long before meals should AMPICILLIN be administered?

1-2 hours

147

For best absorption, how long after meals should AMPICILLIN be administered?

2-3 hours

148

Penicillin V TRADE NAME

Pen-Vee-K

149

Pen-Vee-K GENERIC NAME

Penicillin V

150

PENICILLIN V Use

resp. infection, scarlet fever, otitis media, pneumonia, skin and soft tissue infections, gonorrhea, gram + cocci, gram - cocci, gram + bacilli, gram - bacilli

151

AMPICILLIN Use

gram + and - cocci, gram + and - bacilli

152

PENICILLIN V Action

Interferes with cell wall replication of susceptible organisms. The cell wall, rendered osmotically unstable, swells and bursts from osmotic pressure.

153

PENICILLIN V Side/Adverse effects

Coma, Seizures, N, V, D, Glomerulonephritis, Bone marrow depression, Granulocytopenia, Anaphylaxis, Vaginitis, Oliguria, Proteinuria, Hematuria

154

What are the nursing implications for administering PENICILLIN V po?

administer on empty stomach for best absorption, storage in dry, tight container, oral suspension refrigerated for two weeks

155

What are the nursing responsibilities when caring for clients receiving antibiotics?

Assess for infection, I&O, assess renal function, blood studies, erythema, culture and sensitivity before med started, assess for superinfection, educate client to use medication as prescribed

156

How do you assess for infection?

Temperature, characteristics of sputum, wounds, urine, stools, before, during, and after every treatment

157

What should you report about I&O if you suspect infection?

Any hematuria or oliguria

158

Why are renal studies important in patients on antibiotics?

Most antibiotics are excreted slowly in poor renal function and toxicity may occur rapidly.

159

What blood studies should be preformed in a person receiving antibiotics?

WBC, RBC, Hct, Hgb, bleeding time

160

What renal studies should be preformed for a patient receiving antibiotics?

urinalysis, protein, blood

161

What is erythema?

A redness associated with skin rashes

162

When should you assess for erythema in a patient who is receiving antibiotics?

After administration of antibiotics to one weeks after discontinuing medication

163

What is a superinfection?

An infection occurring during antimicrobial treatment for another infection.

164

What factors contribute to a development of bacterial resistance to antibiotics?

over prescription of antibiotics, Use of inappropriate antibiotics for the infecting organism, Incomplete use of antibiotic prescriptions as symptoms subside, Harboring and spreading of resistant organisms by carrier who remain symptom free and unaware that they have been inflected, increased use of antibiotics in farming contaminating milk and meat

165

What is a resistant strain?

The ability of a microorganism to remain unaffected by an antimicrobial agent.

166

Four strategies in the CDC 12 Step Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Prevent Infection, Diagnose and treat infection effectively, Use antimicrobials wisely, Prevent Transmission

167

What is Hemostasis?

Considered part of the inflammatory phase in which the body responds by initiating a complex process to stop bleeding.

168

What are the phases of wound healing?

Inflammatory, Proliferation, Maturation

169

What does vasoconstriction do in the inflammatory phase?

Helps slow blood to any ruptured vessels, platelet aggregation, activation of the coagulation cascade and the formation of fibrinous clot to stop bleeding

170

What is the inflammatory process usually called in terms of phases of wound healing?

defensive phase

171

How long does the defensive phase (inflammation) usually last?

4-6 days

172

What is the main function of the defensive phase (inflammation)?

Removes bacteria and cellular debris from the wound

173

What do neutrophils do?

Destroy bacteria

174

What do Macrophages do?

Destroy any remaining bacteria and clean the wound of cellular debris

175

Initial vasoconstriction quickly turns into what early on in the inflammatory phase?

vasodilation to facilitate an increased blood flow and release chemoattractants which include WBCs

176

When does proliferation take place?

3-4 days after injury

177

What is proliferation?

True beginning of healing

178

Granulation Tissue

has a beefy, shiny, granular appearance and contracts to help pull the sides of the wound together

179

What is done during the proliferation phase in terms of granulation tissue?

Angiogenesis granulation tissue is formed to help close the defect. Within and beneath the granulation tissue, the injured blood vessels are reformed to bridge the wound

180

What is done in terms of collagen during the proliferation phase?

collagen is generated by fibroblasts within this tissue to give it tensile strength and structure and protein elastin to provide elasticity

181

What is the nurse's role during the proliferation phase?

Must assess for adequate nutritional and hydration intake, administer multivitamins, vitamin C and zinc

182

What must happen if wound is to heal without a scar?

Epithelial cells eventually meet to close the wound without a scar

183

When does the maturation phase take place?

4-24 days depending on the initial severity

184

What is the purpose of maturation?

To restore strength to damaged tissue by reorganizing the collagen fibers into larger bundles and a stronger mesh beneath the scar

185

What is the problem about scar tissue?

It only regains 80% of the tensile strength of undamaged tissue and will always be at risk for reinjury

186

How long does maturation last?

can occur anywhere for a few weeks up to two years

187

What are the three types of wound healing?

Primary intention, secondary intention, and tertiary intention

188

What is Primary Intention?

clean cut edges, approximated by sutures, surgical staples or other means, acute wounds secondary to surgical procedures or trauma, lower risk of infection

189

When does a primary intention wound heal?

4-14 days

190

What is Secondary Intention?

significant tissue loss, edges can not be brought together, healing takes place more slowly, greater risk of infection, fills with granulation tissue and epithelialization gradually takes place from the wound margins, chronic wounds caused by underlying pathologies such as diabetes and pressure ulcers

191

What is Tertiary Intention?

combination of primary and secondary, Surgical wound intentionally left open for several days to allow infection or edema to resolve or to drain exudates from the wound, assessed and managed as an open wound healing by secondary intention, once edema has resolved and bacteria has decreased, wound can be closed or covered with a skin graft, more rapid healing with less risk of infection

192

Red Wound Description

Late regeneration phase. Granulation Tissue Present

193

Red Wound Goal

Protect

194

Red Wound Interventions

cleanse gently, avoid use of dry dressing, apply a topical antimicrobial, apply a transparent or hydrocolloid dressing, change the dressing infrequently

195

Yellow Wound Description

Liquid to semiliquid slough often present with purulent drainage

196

Yellow Wound Goal

Cleanse

197

Yellow Wound Interventions

Irrigate the wound, apply wet to dry dressings, Use absorbent materials, Consult with MD about topical antimicrobial

198

Black Wound Description

Covered with a thick necrotic tissue or eschar

199

Black Wound Goal

Debride

200

Black Wound Interventions

Perform sharp, mechanical, chemical, or autolytic debridement, Hydrotherapy may be used

201

What is hydrotherapy?

Continuous tub baths, wet sheet packs or shower sprays

202

What are the purposes of Wound Irrigation?

Clean the area, apply heat and hasten the healing process, apply an antimicrobial solution

203

Hydrogen Peroxide (H2O2)

softens and removes exudate and debris

204

Normal Saline (0.9% NaCl or 0.9% NS or Sodium Chloride)

Irrigation of clean or noninfected wounds, safest and most appropriate solution for open wounds

205

Providone Iodine/Betadine

Broad spectrum effectiveness against bacteria, spores, fungi, viruses when used on intact skin or small clean wounds

206

Lactated Ringer's (LR)

Irrigation of clean or noninfected wounds

207

Water (H2O)

Cleansing of clean or noninfected wounds

208

What are factors that inhibit wound healing in older adults?

Vascular changes, Collagen tissue is less flexible, Scar tissue is less flexible, Changes in immune system result in a decreased delivery of oxygen, Nutritional deficiencies, Diabetes or cardiovascular disease, Cell renewal is slower

209

Who heals the fastest?

Healthy children and adults

210

What are the nutrients most essential for wound healing?

Protein, Carbohydrates, Lipids, Vitamin A, Vitamin C, Iron, Zinc, Copper

211

Why is exercise important for wound healing?

Good circulation and because blood brings oxygen and nourishment to the wound, more likely to heal quickly

212

Why is smoking negative for wound healing?

Smoking reduces the amount of functional hemoglobin and limiting oxygen carrying capacity of blood and constricts arteries

213

What are medications that affect wound healing?

Anti-inflammatory, Anti-neoplastic, Anti-biotics (prolonged use susceptible to wound infection by resistant organisms

214

What is the significance of the diagnostic test used to monitor blood coagulation?

Platelets move out of capillary to seal the wounded area. It is the clotting factor

215

Platelet Count Normal Adult

150,000-400,000 mm^3

216

Increased Platelet Count Finding

Malignant disorder, Polycythemia

217

Decreased Platelet Count Finding

Chemotherapy, Thrombocytopenic purpura, Viral Infections, AIDS, Lupus

218

What is Stress?

A condition in which the human being responds to changes in its normal balanced state. All people experience. A nonspecific demand requires an individual to respond or take action.

219

What is a Stressor?

Any event or stimulus that causes an individual to experience stress. Internal, external, developmental, or situational

220

Physical Manifestation of Stress

Can threaten a person's homeostasis. Activation of sympathetic nervous system and neuroendocrine system.

221

Verbal Manifestation of Stress

Voice changes, Voice tremors, Increased questioning, Communication may be difficult to understand

222

Motor Manifestation of Stress

restlessness, temors, inability to relax, sleeplessness, poor motor coordination

223

What is a NUR DX that comes to mind when thinking of the motor manifestations of stress?

Risk for Falls

224

Psychological/Emotional Manifestations of Stress

Anxiety, Fear, Anger, Depression

225

Cognitive/Intellectual Manifestations of Stress

Thinking responses that include problem-solving, Structuring, Self-control/self-discipline, Suppression, Fantasy

226

Social Manifestations of Stress

May alter a person's relationships with others

227

Spiritual Manifestations of Stress

Can challenge one's beliefs and values

228

What is Anxiety?

A state of mental uneasiness, a persistent feeling of dread, apprehension, or foreboding. It is a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. A common reaction to stress.

229

Four points about Anxiety

The source of anxiety is usually unidentifiable, Anxiety is typically related to an anticipated event, Anxiety is vague, Anxiety results from a psychological or emotional conflict

230

What is Fear?

An emotion or feeling of apprehension aroused by impending or seeming danger, pain or another perceived threat. The object of fear may or may not be based in reality

231

Four points about Fear

The source of fear is identifiable, Fear can be past/present/future based, Fear is specific or definite, Fear results from a specific physical or psychological event/object/or phenomenon

232

What are the four levels of anxiety?

mild, moderate, severe, panic

233

Mild Anxiety

Produces a slight arousal state that enhances perception, learning, and productive abilities. There is a slight increase in perceptual field and increased alertness. Ability to relate thoughts and ideas coherently is maintained. Most health people experience mild anxiety that prompts a person to seek information and ask questions

234

Moderate Anxiety

Increases the arousal state to a point where the person expresses feelings of tension, nervousness, or concern. Perceptual abilities are narrowed. Attention is focused more on a particular aspect of a situation with blocking of peripheral stimuli to a small extent. Some decrease in seeing, hearing, comprehending, but it is possible to focus attention when directed to.

235

Severe Anxiety

Perceptual field is greatly reduced - only able to focus on a few details. Inability to think clearly, very specific and concrete directions are needed for the person to function. Behaviors are aimed at relief of anxiety-laden situation. The person, unable to focus on what is really happening, focuses on only 1 specific detail of the situation generating the anxiety. At this level the anxiety consumes most of the person's energy and intervention is required

236

Panic

An overpowering, frightening level of anxiety causing the person to lose control. There is severe incapacitation and poor judgement. The person can not think clearly or do things even when directed. Contact with reality is unstable, and perceptions can be altered to the point where the person distorts events. Immediate escape from the situation is sought. This level of anxiety is less frequently experienced than other levels of anxiety.

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Selye's definition of Stress

The nonspecific response of the body to any kind of demand made on it

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What does Selye call the nonspecific response?

General Adaption Syndrome

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Describe the General Adaption Syndrome

Non-specific stress occurs --> Sympathetic Nervous System --> Hypothalamus --> Increase in CRH --> Anterior Pituitary ---> Increase in ACTH --> Adrenal Cortex OR Adrenal Medulla --> If Adrenal Cortex ---> Mineralocorticoid OR Glucocorticoids IF Adrenal Medulla --> Epinephrine OR Norepinephrine

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Mineralocorticoid

Proinflammatory. Na+ retention protein anabolism

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Glucocorticoids

Anti-inflammatory. Protein catabolism. Gluconeogenesis

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Norepinephrine

Peripheral Vasoconstriction. Decreases blood to kidney --> increase in renin = increase in BP

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Epinephrine

Increase myocardial contractility/output, increase in bronchial dilation/increase in oxygen, increase blood clotting, increase in metabolism and energy

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What are the three stages of Selye's General Adaption Syndrome?

Alarm Reaction, Stage of Resistance, and Stage of Exhaustion

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What two phases are included in the Alarm Reaction stage of Selye's General Adaption Syndrome?

Shock phase and Countershock Phase

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Alarm Reaction

The body's initial reaction to the stressor which alerts the body's defenses.

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Shock Phase

The stressor is perceived either consciously or unconsciously --> activation of the sympathetic nervous system which releases large amounts of epinephrine, norepinephrine and cortisone into the body --> ready for flight or flight. This response is short lived 1 minute-24 hours

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Countershock Phase

During this time the changes produced in the body during the shock phase are resolved

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Stage of Resistance

This is when the body's adaption occurs - the body attempts to cope with a stressor and to limit the stressor to the smallest area of the body that can deal with it. (manifestations of stress come out at this stage live hives, depression, hypertension, migraines, acne)

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Stage of Exhaustion

The adaption that the body made at the second stage can not be maintained. The effects of the stress may spread to the rest of the body if the stressor has not been obliterated. At the end of this stage the body either returns to normal and rests, or death may be the ultimate end result.

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Denial

Refusing to allow into awareness some aspect of reality that is somehow distressing. It allows the person to overcome weaknesses and achieve success.

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Regression

Returning to earlier modes of behavior and previous interests. Allows person to return to a point in development when nurturing and dependency were needed and accepted with comfort.

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Rationalization

Helps a person to cope with the inability to meet goals or certain standards

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Effect of stress on Physiologic

altered elimination pattern, change in appetite, altered sleep pattern

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Effect of stress on Safety and Security

expresses nervousness and feelings of being threatened, focuses on stressors and inattention to safety measures

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Effect of stress on Love and Belonging

isolated and withdrawn, becomes overly dependent, blames others for own problems

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Effects of stress on Self-Esteem

fails to socialize with others, becomes a workaholic, draws attention to self

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Effects of stress on Self-Actualization

preoccupied with own problems, shows lack of control, unable to accept reality

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Ways to minimize anxiety and stress

regular exercise, optimal nutrition, adequate rest and sleep, effective time management, minimize anxiety as able, mediate anger, teach/use relaxation techniques, crisis intervention

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Therapeutic Nursing Interventions to Minimize Stress and Anxiety

determine situations that precipitate anxiety and identify signs of anxiety, verbalize feelings, perceptions and fears as appropriate, identify personal strengths, recognize usual coping patterns and differentiate positive from negative coping mechanisms, identify new strategies for managing stress, identify available support systems

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What are things an RN needs to do in order to minimize stress and anxiety

listen attentively and try to understand the client's perspective on the situation. Provide an atmosphere of warmth and trust; convey a sense of caring and empathy. Provide factual information as needed to prepare clients for tests, treatments, and so on. Use short, clear sentences. Encourage clients to participate in the plan of care; give them choices about appropriate aspects of care. Stay with clients as needed to promote safety and feelings of security and to reduce fear. Decrease stimuli.

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What can you teach clients about minimizing stress and anxiety?

The importance of exercise, a balanced diet, and rest and sleep. Support groups. Educational programs available such as time management, assertiveness training, and meditation groups.

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Iorazepam TRADE NAME

Ativan

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Ativan GENERIC NAME

Iorazepam

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Iorazepam Use

Anxiety, irritability in psychiatric or organic disorders, preoperatively, insomnia, adjunct in endoscopic procedures

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Iorazepam Action

Potentiates the actions of GABA, especially in system and reticular formation

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Iorazepam Adverse Effects

Drowsiness. Can lead to tolerance and dependency issues.

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Iorazepam Nursing Considerations

Do not drive or operate machinery while taking this medicine.

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Define Anxiety

A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, (the source often nonspecific or unknown to the individual), a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

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Defining Characteristics Fear

report of alarm, apprehension, being scared, increased tension, decreased self-assurance, dread, excitement, jitteriness, panic, terror, diminished productivity, learning ability, problem solving, identifies object of fear, stimulus believed to be a threat, attack or avoidance behaviors, impulsiveness, increased alertness, narrowed focus on the source of the fear, anorexia, diarrhea, dry mouth, dyspnea, fatigue, increase in perspiration, pulse, RR, systolic BP, muscle tightness, N, V, pallor, pupil dilation

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Defining Characteristics Anxiety

Diminished productivity, Expressed concerns due to change in life events, Extraneous movement, Fidgeting, Glancing About, Insomnia, Poor eye contact, restlessness, Scanning, Vigilance, Apprehensive, Anguish, Distressed, Fearful, Feelings of inadequacy, Focus on Self, Increased Irritability, Jittery, Overexcited, Painful increased helplessness, Persistent increased helplessness, Rattled, Regretful, Uncertainty, Worried, Facial tension, Hand Tremors, Increased Perspiration, Increased Tension, Shakiness, Trembling, Voice Quivering, Anorexia, Cardiovascular excitation, D, Dry mouth, Facial Flushing, Heart pounding, Increased BP, Increased P, Increased reflexes, Increased R, Pupil Dilation, Respiratory Difficulties, Superficial vasoconstriction, Twitching, Weakness, Abdominal pain, Decreased BP, Decreased P, Faintness, Fatigue, N, Sleep Disturbance, Tingling in extremities, Urinary Frequency, Urinary Hesitancy, Urinary Urgency, Awareness of physiologic symptoms, Blocking of thought, Confusion, Decreased perceptual field, Difficulty concentrating, Diminished ability to problem solve, Fear of unspecified consequences, Forgetfulness, Impaired Attention, Preoccupation, Rumination, Tendency to blame others

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Related To Factors Anxiety

Change in: economic status, environment, health status, interaction patterns, role function, role status, exposure to toxins, familial association, heredity, interpersonal contagion, interpersonal transmission, maturational crises, situational crises, stress, substance abuse, threat of death, threat to: economical status, environment, health status, interaction patterns, role function, role status, self concept, unconscious conflict about essential goals of life, unconscious conflict about essential values, unmet needs

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Definition of Fear

Response to perceived threat that is consciously recognized as danger

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Related To Factors Fear

innate origin (sudden noise, height, pain, loss of physical support), innate releasers (neurotransmitters), language barrier, learned response (conditioning, modeling from or identification with others, phobic stimulus, sensory impairment, separation from support system in potentially stressful situation (hospitalization, hospital procedures), unfamiliarity with environmental experience

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Chief Complaint

Answers the question "What brings you here today?"

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History of Present Illness

Includes aggravating and alleviating factors

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Past History

Includes childhood illnesses and prior operations

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Medications

List of prescription and non-prescription medications the client is currently taking

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Family History

Reveals risk factor for hereditary disorders

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Lifestyle

includes work, sleep, exercise, diet, caffeine, alcohol, ADLs

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Social Data

Includes role of family, friends, significant others, education religion, occupation, economic factors

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Review of Systems

Focuses on subjective data regarding health according to body system

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Psychological Data

Includes major stressors, usual coping patterns, communication style

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Pallor

The loss of underlying red tones

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Cyanosis

A bluish or ashen gray discoloration

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Jaundice

A yellowish tinge

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Erythema

An abnormal redness on the skin and may appear as a bluish, purplish, or darkened discoloration in individuals with dark skin tones

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Pallor in people with light skin may be evident in which body parts?

Face, conjunctiva of the eyes, and nail beds

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What does pallor look like in people with dark skin?

Ashen gray or yellow

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Cyanosis can be detected in dark skin how?

conjunctiva of the eyes and palms and soles

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How will erythema look in a dark skin patient?

bluish, purplish, or darkened discoloration

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Name all pulse sites

temporal, carotid, apical, brachial, dorsalis pedis, radial, femoral, popliteal, posterior tibial

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How do you assess apical pulse?

With a stethoscope

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What does a weak or thready peripheral pulse (1+) indicate?

Possible peripheral artery disease or decreased cardiac output. This would warrant notification of the PCP so further testing could be performed

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What is the significance of compression of arteries?

Can cause decreased blood supply to the area, resulting in decreased or absent palpable pulses, pale, cool skin and sluggish capillary refill. It can also cause decreased circulation to muscles and nerves resulting in severe pain and lack of nerve and muscle function.

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What is the significance of compression of veins?

Can cause obstruction to blood flowing from the area, resulting in cyanosis and edema. This edema can contribute to further worsening of circulation.

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Conduction

Transfer of heat from one molecule to another molecule of lower temperature

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Convection

Dispersion of heat by air currents

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Radiation

Transfer of heat from the surface of one object to the surface or another without contact between the two objects

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What is the significance of compression of efferent nerves?

Can cause decrease or absent messages to muscles. This would be manifested by decrease or absent motion

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What is the significance of compression of afferent nerves?

Can cause decrease or absent sensation or + paresthesias. This would be manifested by lack of withdrawal from painful stimuli.

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How do you prevent permanent damage to veins, arteries, and nerves?

monitor the status of CMS.

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What is CMS?

circulation, motion, and sensation of extremity

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What are the signs of impairment of an extremity?

edema, changes in color, complaints of abnormal sensation, decrease in sensation, decrease in strength or motion, complaints of increasing pain, changes in temperature of extremity, changes in your assessment of peripheral pulses

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What is parethesia

An abnormal sensation. "Pins and needles"

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What is another way to say CMS?

Neurovascular status

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When is it important for the RN to assess CMS status?

anytime there is a reason to suspect the client's neurovascular status might be compromised, if it is ordered, after surgery of an extremity, application of a cast or splint, application of a compressive wrrap or tourniquet, placement of a catheter in an artery or vein

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What should you do if there is a change in baseline of the client's neurovascular status

Report promptly to client's PCP

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How long should ice bags be left in place?

15-30 minutes

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When should heat be immediately discontinued?

With evidence of any redness which could lead to development of a burn, or complaints of pain/discomfort

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What is the rebound phenomenon?

Rebound phenomenon occurs at the time maximum therapeutic effect of the heat/cold application is achieved and the opposite effect begins.

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When does heat produce maximum vasodilation?

20-30 minutes

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When does cold produce maximum vasoconstriction?

When involved skin reaches a temperature of 15 C or 60 F

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What is critical content to be reported and documented about the application of heat and cold?

method of application, area of application, duration of treatment, client response

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Client assessments to be made during application of heat

assess for edema/worsening of existing edema, assess for decrease in BP --> fainting --> falls

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Client assessments to be made during the application of cold

assess for signs and symptoms of impaired circulation --> tissue death. mottled or bluish skin color, numbness, blisters, pain. Assess for increase in BP

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Before initiating heat or cold application, what must the nurse assess?

condition of the equipment to be used, body part involved (some body parts are more sensitive than others), damage to body surface (open tissue or abraded skin is more sensitive to temperature variations), body surface area (an individual is less tolerant of temp changes over a large area of the body), age (infants, children, elderly more sensitive), physical condition

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What are the therapeutic benefits of heat?

increase blood flow to injured body part, increase delivery oxygen and nutrients, decrease venous congestion in injured areas, increase movement of waste products and fluids away from the injured areas, increase blood flow, increase warmth, increase phagocytosis, promotes soft tissue healing, soothing and relaxing

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What are the therapeutic benefits of cold?

decrease flood flow to limit swelling and bleeding, decrease movement of wastes from the injured areas, decrease in oxygen needs of the tissues, decreases bacterial growth, decreases phagocytosis, decreases nerve impulses to the brain (numbing), decreases pain

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Arteries

Carry blood away from the heart

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Brachial

at bend of elbow, medial to the biceps tendon and muscle

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Radial

on the flexor surface of the wrist, laterally

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Ulnar

on the flexor surface of the wrist, medially

324

Femoral

in groin

325

Popliteal

behind knee

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Dorsalis pedis

on the dorsum of the foot

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Posterior tibial

behind the medial malleolus of the ankle

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Veins

Carry blood back to the heart

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Deep Leg Veins - Femoral

just medial to the femoral artery below the inguinal ligaments

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Superficial Leg Veins - Great saphenous

runs from the dorsum of the foot to the groin

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Superficial Leg Veins - Small/Lesser saphenous vein

from the dorsum of the foot to the back of the knee

332

What are deep and superficial veins connected by?

communicating veins

333

Examine arms for...

edema, discoloration, rashes, scars, changes in skin texture, hair distribution, venous patterns, temperature, arterial pulse, amplitude scale, radial pulse symmetry, ulnar pulse, brachial pulse

334

Examine legs for....

symmetry of size, shape, color, swelling, discoloration, rashes, scars, ulcers, abnormal venous patterns, color and texture of skin and nail beds and distribution of hair of feet and toes

335

Palpate legs for...

temperature of feet and lower legs with backs of your fingers, palpate femoral pulse (fingers midway between anterior superior iliac spine and symphysis pubic, pressing deeply below inguinal ligament), tenderness of femoral vein (just medial to femoral pulse), popiteal pulse (flex knee, press fingertips into popliteal fossa slightly lateral to the midline), dorsalis pedis pulse (over dorsum of foot just lateral to extensor tendon of big toe. this pulse may be congenitally absent.), posterior tibialis (curve fingers behind and slightly below medial malleolus of ankle), edema, calf muscles (compress against tibia, checking for tenderness, increased firmness or tension)

336

Hypervolemia

An increase in the blood plasma. Increase hct and hgb can indicate this

337

When are high WBC counts seen?

Bacterial infection

338

When are low WBC counts seen?

Viral infection

339

Approximated

Closed (wound)

340

What is hemostasis?

The cessation of bleeding resulting from vasoconstriction of the larger blood vessels in the affected area, retraction of injured blood vessels, the deposition of fibrin (connective tissue), and the formation of blood clots in the area

341

Which phase of wound healing does hemostasis take place?

Inflammatory

342

What happens when a wound does not experience epithelialization?

Eschar (area becomes covered c dried plasma proteins and dead cells)

343

What do fibroblasts synthesize?

Collagen

344

What do you assess c untreated wounds?

bleeding, infection, swelling, pain, shock

345

In untreated wounds, how do you control bleeding?

apply direct pressure and elevate

346

In untreated wounds, how do you prevent infection?

Flush with normal saline, cover wound c clear dressing, wrap to approximate wound edges

347

In untreated wounds, how do you control swelling and pain?

ice

348

What are the signs of shock?

Low BP, pallor, rapid thready pulse, cold clammy skin

349

Papule

circumscribed, solid elevation of skin less than 1cm. Ex. Warts, Acne, Pimples, Elevated Moles

350

Vesicle

A circumscribed, round or oval, thin translucent mass filled with serous fluid of blood less than 0.5cm. Ex. Herpes simplex, early chicken pox, small burn blister

351

What is this picture an example of?

vesicle

352

What is this picture an example of?

papule

353

Skin Color Normal Findings

light-deep brown, ruddy pink-light pink, yellow overtones-olive

354

Abnormal Skin Color Findings

pallor, jaundice, errythema, cyanosis

355

Skin Color Uniformity Normal Findings

uniform except for in areas exposed to the sun and in areas of lighter pigmentation (palms, lips, nail beds) in darker skinned people

356

Abnormal Skin Color Uniformity Findings

hyperpigmentation of hypopigmentation

357

Normal Skin Lesions

freckles, some birthmarks that have no change since childhood, and some long-standing vascular birthmarks such as strawberry or port-wine hemangiomas, some glast and raised nevi, no abrasions or other lesions

358

Abnormal Skin Lesion Findings

various interruptions in skin integrity, irregular multipcolored or rasied nevi, some pigmented birthmakrs such as melanocystic nevi and some vascular birthmarks such as cavernous hemangiomas. deviations from normal may not be dangerous or require treatment so assessment by an advanced-level practitioner is required

359

Normal Findings for Hair

evently distributed hair, thick hair, silky, resistant hair, no infection or infestation

360

Abnormal Findings for Hair

patches of hair loss, very thin hair, brittle hair, excessively oily or dry hair, flaking, sores, lice, nites, ringworm, hirsutism in women, absent or sparse leg hair

361

What can naturally absent or sparse leg hair be an indication of?

Poor circulation

362

Normal Nail Findings

convex curvature, angle of nail plate about 160 degrees, smooth texture, highly vascular and pink in light-skinned clients, dark-skinned clients may have brown or black pigmentation in longitudinal streaks, intact apidermis, promp return of pink or usual color in generally less than 2 seconds

363

Abnormal Nail Findings

spoon nail, clubbing, excessive thickness or thinness or presence of grooves or furrows, beau's lines, discolored or detached nail, bluish or purplish tint, pallor, hangnails, inflammation, delayed return of pink or usual color

364

What is clubbing an indication of?

long term oxygen lack

365

What are Beaus lines an indication of?

severe injury or illness

366

What is spooning an indication of?

iron deficiency anemia

367

Normal peripheral Vascular Findings

symmetric pulse volumes, full pulsations, presence of distention and nodular bulges at calves, when limbs elevated veins collapse and may appear tortuous or distended in older people, symmetric in size, limbs not tender, skin color pink, skin temp not excessively warm or cold, no edema, skin texture resilient and moist, immediate return of color for capillary refill test

368

Abnormal Peripheral Vascular System Findings

asymmetric volumes, absence of pulsation, decreased, weak, thready pulsations, increased pulse volume, distended veins in the thigh and/or lower leg or on posterolateral part of calf from knee to ankle, swelling of one calf or leg, tenderness on palpation, pain in calf muscles with forceful dosiflexion of the foot, warmth and redness over vein, cyanotic, pallor that increases with limb elevation, dusky red color when limb is lowered, brown pigmentation around ankles, skin cool, edema, skin thin and hiny or thick waxy shiny and gragile with reduced hair and ulceration, delayed return of color for capillary refill test 

369

Mole

A solid tan, black, or skin-toned color round or oval with flat or dom-like surface that is smaller than 6mm in diameter. it has well-defined edges and in existence before age 30

370

Macule

flat, circumscribed, <1cm diameter