Untitled Flashcards Set

Stage 1 Pressure Ulcer

Intact skin with non-blanchable redness; may feel warmer or cooler than surrounding skin.

Appearance of Stage 1 Pressure Ulcer

Red or discolored skin, possibly with changes in temperature, firmness, or sensation.

Symptoms of Stage 1 Pressure Ulcer

Pain, burning, or itching are common.

Treatment for Stage 1 Pressure Ulcer

Focus on removing pressure, keeping the area clean and dry, and addressing any underlying causes.

Stage 2 Pressure Ulcer

Partial-thickness skin loss with exposed dermis, appears as an open sore, blister, or abrasion.

Appearance of Stage 2 Pressure Ulcer

Wound bed is viable, pink or red, and may be moist.

Symptoms of Stage 2 Pressure Ulcer

Pain, swelling, warmth, and possible drainage or pus.

Treatment for Stage 2 Pressure Ulcer

Clean with saline solution, protect with moisture barriers, and address underlying causes.

Stage 3 Pressure Ulcer

Full-thickness skin loss with damage to subcutaneous tissue, appears as a crater-like wound.

Appearance of Stage 3 Pressure Ulcer

Wound extends into the fat tissue, may have a bad odor or signs of infection.

Symptoms of Stage 3 Pressure Ulcer

Pain, swelling, warmth, and possible drainage or pus.

Treatment for Stage 3 Pressure Ulcer

Wound care, addressing underlying causes, and possibly surgical intervention.

Stage 4 Pressure Ulcer

Full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone.

Appearance of Stage 4 Pressure Ulcer

Wound extends deeply into tissues, may have rolled edges or eschar.

Symptoms of Stage 4 Pressure Ulcer

Extreme pain, drainage, dead tissue, and signs of infection.

Treatment for Stage 4 Pressure Ulcer

Often requires surgical intervention and may involve prolonged recovery.

Pressure Ulcer Stages

A classification system used to assess the severity of skin injuries.

Oxygen Administration - Verify Provider’s Order

Ensure valid prescription for oxygen including flow rate and target saturation.

Oxygen Administration - Gather Supplies

Prepare pulse oximeter, delivery device, tubing, and humidifier.

Oxygen Administration - Perform Hand Hygiene

Wash hands thoroughly before and after the procedure.

Oxygen Safety - No Smoking

Implement a strict no-smoking policy in the area.

Oxygen Safety - Keep Away from Heat Sources

Ensure oxygen delivery system is at least 5 feet away from heat.

Oxygen Safety - Check Oxygen Levels

Verify portable tanks are adequately filled before transport.

Oxygen Safety - Ensure Tubing is Patent

Check for kinks, twists, or blockages in the tubing.

Oxygen Safety - 'Oxygen in Use' Signs

Display signs in visible areas indicating oxygen use.

Oxygen Safety - Notify Fire Department

Inform fire department and electric company of oxygen use.

Respiratory Assessment - Focused Assessment

Includes airway, respiratory rate, pulse oximetry, and lung sounds.

Oxygen Delivery Device Selection

Choose delivery device based on patient's condition and prescribed oxygen.

Nasal Cannula

Suitable for lower oxygen needs (1-6 L/min).

Simple Face Mask

Used for moderate oxygen needs (5-10 L/min).

Reservoir Mask

Delivers higher oxygen concentrations (10-15 L/min).

Venturi Mask

Provides a precise oxygen concentration (24% or 28%).

Connect and Set Flow Rate

Connect tubing to flow meter and set the prescribed flow rate.

Ensure Proper Fit

Check that the device fits snugly and comfortably.

Explain the Procedure

Explain the procedure to the patient and obtain consent.

Stages of Infection - Incubation Period

Pathogen enters body and multiplies; no symptoms present.

Stages of Infection - Prodromal Period

Early nonspecific symptoms appear; person may be contagious.

Stages of Infection - Illness Period

Full-blown symptoms develop, immune system actively fights pathogen.

Stages of Infection - Decline Period

Symptoms gradually improve; body recovers.

Stages of Infection - Convalescence Period

Body returns to normal; may experience lingering effects.

Dehiscence

Partial or complete separation of outer wound layers.

Evisceration

Rupturing of a wound.

Eschar

Hard, dry, leathery dead tissue.

Granulation Tissue

New tissue that grows and fills in a wound.

Sinus Tract

A tunnel developing between two cavities or an infected cavity and the skin's surface.

Laceration

Skin tear with irregular edges and vein bridging.

Avulsion

Tearing away from supporting structures.

Abrasion

Denuded skin.

Ecchymosis/Contusion

Blood trapped under the surface of the skin.

Hematoma

Tumor-like mass of blood trapped under the skin.

Stab Wound

Incision of skin with well-defined edges caused by a sharp instrument.

Cut Incision

Incision of skin with well-defined edges, usually longer than deep.

Patterned Wound

Wound representing the outline of the object causing the wound.