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List five causes of wounds.
- Surgery
- Trauma
- Unrelieved pressure or friction
- Decreased blood flow through the arteries or veins
- Nerve damage
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A skin tear is
a break or rip in the outer layers of the skin.
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Circulatory ulcers are caused by
decrees blood flow through the artier or veins.
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The heels and inner aspects of the ankles are common sites for
venous ulcers occurs when valves in veins do not close well.
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______ is a condition in which there is death of tissue.
Gangrene
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Arterial ulcers are found:
- Toes
- On top of the toes
- On the outer side of the ankle
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A _________ is an open wound on the foot caused by complications from diabetes.
Diabetic foot ulcer
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Why do you need to check daily the feet of persons with diabetes?
Check for foot damage as it takes several weeks or months for them to heal.
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This type of wound is created for therapy. Surgical wounds are examples.
Intention wound
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First intention
The wound is closed
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Second intention
Contaminated and infected wounds are cleaned and dead tissue removed.
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Third intention
Wound is left open and closed later
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You cannot see _____ hemorrhage. Bleeding occurs inside the body into tissues and body cavities.
internal
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Describe serous drainage.
Serous comes from the word serum. Serum is clear think fluid portion of blood. Serum does not contain blood cells or platelets.
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Explain why tape must not circle the entire body part.
If swelling occurs, circulation to the part is impaired.
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When removing dressings, how is the tape removed?
Remove tape by pulling it forward the wound.
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List six stages of pressure ulcers.
- Stage 1 – Intact skin with redness over bony prominence.
- Stage 2 – Partial-thickness skin loss.
- Stage 3 – Full thickness tissue lose.
- Stage 4 – Full thickness tissue loss with muscle, tendon, and bone exposure.
- Unstageable – full thickness tissue loss with ulcer cover by slough and/ or eschar.
- Suspected deep tissue injury – a purple or maroon area of intact skin or a blood-filled blister.
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A shear is
when layers of the skin rub against each other; when the skin remains in place and underlying tissues moves.
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Where do pressure ulcers usually occur?
Over bumpy prominence
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Why are older and disabled persons at great risk for pressure ulcers?
They are more bedfast
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Describe a Stage 1 pressure ulcer.
The color does not fade with pressure. It way may appear pale, blue, or purple.
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Why do pressure ulcers usually occur over bony areas (pressure points)?
Those are the areas where people apply more pressure to, and the area where the skin is more fragile and doesn’t have much cushion.
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An avoidable pressure ulcer is
from the improper use of the nursing process.
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Define the stages of pressure ulcers:
- Suspected deep tissue injury – Pressure or shear damaged underlying soft tissue.
- Stage 1- Redness over a body prominence.
- Stage 2 – The wound may involve a blister or shallow ulcer.
- Stage 3 – The skin is gone. Subcutaneous fat may be exposed.
- Stage 4 – Slough and eschar may be present.
- Unstageable – Slough is yellow, tan gray, green, or brown.
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____ and ___ healing may signal an infection.
Pain and delayed
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List four key pressure ulcer prevention measures for persons at risk.
- Managing moisture.
- Good nutrition.
- Good fluid balance.
- Relieving pressure ulcers.
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Explain why avoidable pressure ulcers are preventable.
We can provide necessary treatment and services to promote healing, prevent infection, and prevent new ulcers.
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To prevent friction in bed
you can powder the sheets lightly can help decrease friction.
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The total or partial loss of the ability to use or understand language; a language disorder resulting from damage to parts of the brain responsible for language
Aphasia
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An eye disease in which fluid pressure within the eye increases
Glaucoma
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A touch reading and writing system that uses raised dots for each letter of the alphabet
Braille
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Difficulty expressing or sending out thoughts
Expressive aphasia
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Hearing loss in which it is impossible for the person to understand speech through hearing alone
Deafness
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An eye disease in which the lens of the eye becomes cloudy
Cataract
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A ringing, roaring, hissing, or buzzing sound in the ears or head
Tinnitus
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Otitis media is
an infection of the middle ear
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List four obvious signs and symptoms of hearing loss.
- Hearing on the phone.
- Hearing with background noise or in noise areas.
- Flowing conversation when 2 or more people are speaking.
- Hearing voices as mumble or slurred.
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What is the best way to clean a hearing aid?
Follow the nurse’s direction and manufacturer’s instructions.
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The person with ___ cannot use the speech muscles to produce understandable speech.
apraxia of speech
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With ____ aphasia, the person has difficulty understanding language.
receptive
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Glaucoma results in damage to the ____.
optic nerve
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The most common cause of cataracts is
aging
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__________ is a disease that blurs central vision. It damages the macula located in the center of the retina
Age related muscular degeneration
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Everyone with diabetes is at risk for the eye disorder __________
diabetic retinopathy
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Low vision is
vision loss that cannot be corrected with eyeglasses.
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The ______ person sees at 20 feet what a person with normal vision sees at 200 feet.
legally blind
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What is the goal of rehabilitation programs for persons with vision loss?
Help the person adjust to the vision loss and learn to be independent.
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The nurse asks you to remove, clean, and store a patient’s contact lenses. What observations do you need to report and record?
- Eye redness or irritation.
- Eye drainage.
- Complaints of ye pain, blurred vision, or uncomfortable lenses.
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List four cancer risk factors described by the National Cancer Institute.
- Age
- Tabaco
- Radiation
- Infections
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One treatment for cancer involves surgery to remove tumors. Surgery is done for the following reasons:
- Cure
- Control cancer
- Relieve pain
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Chemotherapy involves drugs that
kill cancer cells
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The _____ system protects the body from microbes, cancer cells, and other harmful substances.
immune
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How does the immune system cause diseases?
Autoimmune disorders occur when the immune system attacks its own body’s healthy cells.
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Acquired immunodeficiency syndrome (AIDS) is caused by
Human immunodeficiency virus
-
The AIDS virus is transmitted mainly by:
- Having sex with someone who has HIV.
- Sharing needles, syringes, rinse water, or other equipment used to prepare injection drugs.
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To protect yourself and others from HIV and AIDS, you must follow
Standard precautions and blood bone pathogen standard.
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Persons infected with HIV can spread the virus even without symptoms. How long can a person infected with HIV remain symptom free?
For more than 10 years.
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Shingles is most common in persons over __ years of age.
50
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List five warning signs of stroke.
- High blood pressure
- Smoking
- Diabetes
- High cholesterol
- Heart disease
-
All stroke-like symptoms signal the need for
Rehabilitation
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List four signs and symptoms of Parkinson’s disease.
- Tremors
- Rigid, stiff muscles
- Stooped posture and impaired balance
- Mask like expression
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Symptoms of multiple sclerosis usually start between the ages of
20 and 40
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Amyotrophic lateral sclerosis (ALS) attacks the nerve cells that control
voluntary muscle
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Coma
The person is unconscious, does not respond is unaware and cannot be aroused.
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Vegetative state
The person is unconscious and unaware of surrounding.
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Brain death
Despite complete loss of brain function the heart continues to beat.
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A spinal cord injury usually results from
Sudden traumatic blow to the spine.
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With spinal cord injury, damage to the spinal cord can be complete or incomplete. Describe what occurs when the damage is complete.
No sensory or muscle function below the level of the injury site.
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Joint replacement surgery (arthroplasty) is done to:
- Relieve pain
- Restore join function
- Correct a deformed joint
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Describe an open (compound) fracture.
The broken bone has come through the skin.
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Fractures in infants may signal
child abuse
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A patient is recovering from a hip fracture. After surgery, the person needs to keep the operated leg ______ at all times.
abducted
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_____ is a condition is which there is death of tissue.
Gangrene
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A prosthesis is
an artificial replacement for a missing body part.
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