would care II

Question 1

What phase: red, swollen, firm, warm

Answer 1

inflammatory

Question 2

Evidence of epitheliazation

Answer 2

pale pink cells

Question 3

Mature characteristics

Answer 3

flat, white, pale, soft

Question 4

immature characteristics

Answer 4

raised, red, rigid

Question 5

3 depths of a wound

Answer 5

superficial
partial thickness
full thickness

Question 6

wound extends into epidermis, dermis or both but not subcutaneous

Answer 6

partial thickness

Question 7

epidermis, dermis, subcutaneous

Answer 7

full thickness

Question 8

What are the six stages of pressure injuries

Answer 8

Stage 1-4
unstageable
deep tissue pressure

Question 9

intact skin with non-blanchable erythema

Answer 9

Stage I Non blanchable erythema of intact skin

Question 10

partial thickness skin loss with exposed dermis, viable, pink or red, moist and may present intact or ruptured blister

Answer 10

Stage II Partial thickness skin loss with exposed dermis

Question 11

full thickness loss of skin, fat is visible and ulcer and granulation tissue and epibole (round edges) are often present

• undermining and tunneling may occur
• slough and eschar

Answer 11

stage III Full thickness skin loss

Question 12

full thickness skin and tissue loss with exposed palpable fascia, muscle, tendon ligament or cartilage in the ulcer
-rolled edges, tunneling, undermining often

Answer 12

Stage IIII Full thickness skin and tissue lost

Question 13

when full thickness skin and tissue loss to the extent of tissue damage cannot be determined due to slough or eschar

Answer 13

unstageable pressure injury

Question 14

non blanch able deep red, maroon, or purple revealing dark wound blood or blood filled blister

Answer 14

Deep Tissue Pressure Injury

Question 15

if slough or eschar obscures the extent of the tissue loss this is considered what type of pressure injury?

Answer 15

unstageable

Question 16

Characteristics of Venous Ulcer

Answer 16

• proximal to med. malleolus
• irregular shape
• excessive exudation
• pinkish-red base
• brown purple discoloration

Question 17

Five interventions for venous ulcers

Answer 17

1. pliable non stretchable dressing
2. fitted socks
3. gentle rinsing basin
4. intermittent compression (jobst pump)
5. mild weight bearing exercise

Question 18

superior to lateral malleolus, feet, and toes
irregular shape
pale base with poor granulation
severe pain
gangrene

Answer 18

Ischemic or arterial ulcers

Question 19

Should you elevate arterial ulcers?

Answer 19

NO

Question 20

What are three types of burns

Answer 20

thermal

chemical electrical

Question 21

When are scalds most prevalent?

Answer 21

Children 1-5 years

Question 22

Who is at most risk for for flammable liquid burns?

Answer 22

men 17-30 years

Question 23

Three zones of tissue damage from burns?

Answer 23

Hyperemia
coagulation
stasis

Question 24

irreversible damage in a burn

Answer 24

coagulation zone

Question 25

injured, dies without intervention in burn

Answer 25

stasis

Question 26

minimal cell damage, recovers in burn

Answer 26

hyperemia zone

Question 27

Describe five depths of a burn injury?

Answer 27

Superficial ( epidermis only, sunburn, no blisters) Superficial Partial Thickness (upper layers of dermis, intact blisters) Deep partial Thickness ( destruction of epidermis, dermis) Full Thickness ( ruined epidermis and dermis, no pain. may reach fat) Subdermal ( can reach bone and muscle)

Question 28

what depth of a burn is it if destructs the epidermis and severe damage to dermis. Mixed red and white color, nerve endings can be damaged, along with hair and sweat glands

Answer 28

Deep Partial Thickness

Question 29

Complete destruction of epidermis and dermis, no pain, subcutaneous fat may have damage is what depth of burn

Answer 29

Full thickness burn

Question 30

Complete destruction of all tissue from epidermis to subcutaneous tissue including muscle and bone

Answer 30

Subdermal burn

Question 31

clear drainage

Answer 31

serous

Question 32

blood tinged drainage(vessel dialation)

Answer 32

serosanguineous

Question 33

creamy yellowish containing neutrophils, macrophils, RBC and WBC

Answer 33

Exudate

Question 34

scab

Answer 34

dessication

Question 35

yellow or yellow whitish, dried exudate

Answer 35

Slough

Question 36

white colored, healthy tissue,over hydrated

Answer 36

maceration

Question 37

undermining, crescent shaped wound

Answer 37

undermining

Question 38

tract/sinus deep wound

Answer 38

tunneling

Question 39

Describe Ankle Brachial Index

Answer 39

``` measure brachial (SBP) and ankle SBP in supine and divide ankle/brachial should be about 1.0, if less than .8 arterial insufficiency ```

Question 40

What are the ranges for normal, borderline perfusion, severe ischemia, and critical limb ischemia?

Answer 40

NOrmal 1.0-1.3 | Severe ischemia

Question 41

Turbulane sound or wooshing

Answer 41

bruits

Question 42

Name three arterial vascular tests

Answer 42

1. rubor of dependency 2. venous filling time 3. claudication time

Question 43

Describe Rubor of Dependency (arterial test)

Answer 43

patient supine leg elevated 60 degrees for 1 min (normal has no color change, pallor presents if insufficient blood flow) when leg is placed below heart level, color will change form pink to bright red

Question 44

What causes an abnormal reading of Rubor of Dependency (arterial)

Answer 44

due to reactive hyperemia or rubor or dependency compensating for tissue hypoxia (if its a venous problem veins will allow the blood to back and area will change)

Question 45

Describe Venous Filling Time (arterial test)

Answer 45

- only works in people with competent venous sytems - patient supine at 60 degrees for 1 min then returned - record filling time - if greater than 10-15 = arterial problems

Question 46

Describe Claudication time (arterial test)

Answer 46

treadmill walk for 1 mile until calf pain

Question 47

What are three venous tests for vasculature?

Answer 47

1. percussion test 2. trendelenburg's Test (should take about 30 seconds if not, incompetent) 3. Holms Sign (DVT test)

Question 48

What should a light touch sensation feel like

Answer 48

10g or 5.07 filament