B248 exam 2

  1. 3 factors that contribute to pressure ulcer development
    pressure intensity, pressure duration, tissue tolerance
  2. risk factors for pressure ulcers
    impaired sensory perception, alterations in LOC, impaired mobility, shear, friction, moisture
  3. What kind of light to use when assessing darker skin?
    halogen/ natural lighting
  4. Stage I pressure ulcer
    intact skin with nonblanchable redness
  5. Stage II presssure ulcer
    Partial-thickness skin loss involving epidermis, dermis, or both
  6. Stage III pressure ulcer
    Full-thickness skin loss with visible fat
  7. Stage IV pressure ulcer
    Full-thickness skin loss with exposed bone, muscle, or tendon
  8. What indicates a patient is at risk for pressure ulcers on the Norton's scale?
    14 or less
  9. What score indicates a patient is at risk for pressure ulcers on the Braden scale?
    • 18 or less
    • lower scores means greater risk
  10. Define a wound
    disruption in the integrity and function of tissues in the body
  11. Healing stages of Wounds
    • Inflammatory (1-3days)
    • Proliferative(3-24days)
    • Remodeling(up to 1yr)
  12. When is the greatest risk for hemorrhages?
    24-48hrs after surgery
  13. define evisceration
    total edge seperation with organ protrusion
  14. define dehiscence
    partial seperation of edges
  15. wet to dry dressing
    a form of mechanical debridement
  16. hydrocolloid dressing
    protects the womb from surface contamination
  17. wet to wet dressing
    topped with dry..to keep moist for healing
  18. hydrogel
    maintains a moist surface to support healing
  19. wound V.A.C.
    uses negative pressure to support healing
  20. principles of cleansing wound (5)
    • start in middle and move outwards
    • never go back to middle with same swab
    • usually done 3 times
    • may irrigate to flush debris
    • assess for tunnel or ledge
  21. define debridement
    • remove necrotic tissue
    • methods used depends on individual's factors; chemical,, mechanical, autolytic, surgical
  22. kidneys
    remove waste from the blood to form urine
  23. ureters
    transport urine from the kidneys to the bladder
  24. bladder
    reservoir for urine until the urge to urinate develops
  25. urethra
    urine travels from the bladder and exits through the urethral meatus
  26. normal urine that indicates you are well hydrated should be..
    pale yellow, clear
  27. approx bladder capacity
    600 ml
  28. when can a person "feel" like they need to urinate?
    150-200 ml
  29. urinary retention
    • an accumulation of urine due to the inability of the bladder to empty . overflow can occur
    • goes frequently ...can see in post-op pts
  30. UTI
    urinary tract infection; may occur from procedure or catherization. 40% of HAI's. women more often than men
  31. urinary diversion
    diversion of urine to new external opening (nephrostomy, ileal loop, continent diversion)
  32. urinary incontinence
    • involuntary leakage of urine, continuous or intermittent..more common in older age
    • but not a NORMAL aging process
  33. kegal exercises
    contraction on the pelvic floor to help improve urinary muscles
  34. micturation
  35. catherization
    • insertion of a catheter the the urethra into the bladder to provide a continuous flow of urine
    • insertion; need order, strict sterile technique
Card Set
B248 exam 2
practice for exam 2