Foundations Vocab

What are the earliest signs of hypoxia and hyperprofusion?

restlessness

Partial Airway Blockage

stridor

Low-pitched, coarse rattling cause by mucus in the bronchi

rhonchi

High-pitched whistling caused by narrowed lower airways

wheezing

Crackling/popping caused by fluid in the alveoli

crackles

Minimum MAP needed for organ perfusion?

60mmHg

What is mottling a sign of?

poor cardiac output

Decreased urine output is a sign of ___

impaired perfusion

A MEWS score greater than or equal to ___ is a sign of clinical decline

3

What is the expected RASS score?

0

1 ounce = ? mL

30

1 kg = ? pounds

2.2

1 L = ? pounds

2.2

How to Calculate Pack Years

number of packs smoked per day x number of years smoked

The avascular layer of the skin

epidermis

The highly vascular, connective tissue layer of the skin

dermis

The layer of the skin that provides heat retention and cushion

hypodermis

Xerosis

excessive dryness

Diaphoresis

excessive sweating

Pruritus

itching

Urticaria

hives

Ecchymosis

bruising

Alopecia

hair loss

Erythema

redness

Where is jaundice best seen?

the sclera of the eyes

Where is cyanosis most noticeable?

nailbeds

What lesion shape is a ring with an area of central clearing?

annular

A lesion is considered large when it is greater than ___

1cm

A lesion is considered small when it is less than ___

1cm

Flat, small, non-palpable, circumscribed lesion

macule

Larger version of a macule

patch

Small, elevated, superficial lesion filled with serous fluid

vesicle

Lesion similar to a vesicle, but filled with purulent fluid

pustule

Elevated, circumscribed, encapsulated lesion that is deeper into the skin

cyst

Firm/solid, small, elevated, circumscribed lesion

papule

Similar to a papule, but larger (1-2 cm)

nodule

Large, elevated, rough lesion with a flat top

plaque

Elevated, irregular-shaped area of cutaneous edema

wheal

Loss of epidermis from repeated irritation

excoriation

Loss of epidermis from friction

abrasion

Concave, crater-like sore on the skin; size and depth vary

ulcer

ABCDE of skin cancer

asymmetry, border, color, diameter, evolution

Mass of small, blanchable blood vessels

cherry angioma

Raised, thickened plaques common in elderly patients

seborrheic keratosis

Tiny, non-blanchable red spots on the skin that are a result of tiny hemorrhages within the dermis; can indicate a medical emergency

petechiae

Reddish-purple discoloration of the skin that is non-blanchable; not caused by external injury

purpura

Flat, non-palpable reddish-purple spots on the skin; created from blunt force trauma

ecchymosis

Skin turgor

skin’s elasticity

To test skin turgor on an adult, pinch the ___

back of the hand or forearm

To test skin turgor on an infant, pinch the ___

abdomen

What is the unexpected finding of skin turgor?

tenting

Incontinent patients should be checked ___

every hour

Patients should be repositioned ___

every two hours

Fungal skin infection

candidiasis

STAND skin bundle

score on braden scale, turn, apply barrier cream, nutrition, discuss with specialist

A score less than ___ on the Braden Scale indicates risk for pressure injuries

18

Phases of wound healing

hemostasis, inflammation, proliferation, maturation/remodeling

Hemostasis

scab formation

Inflammation

edema, erythema, exudate

proliferation

granulation and epithelialization

Pink/red and bumpy skin found during healing phases

granulation

Pink, shiny tissue found during healing phases

epithelialization

Scarring phase of healing

maturation/remodeling

Wound edges are sutured, stapled, or glued

primary intention

Wound edges cannot be approximated

secondary intention

Wound closure is postponed before suturing/skin graffing

tertiary intention

Red streaks going up the arm caused by lymphatic tube infection

lymphangitis

Light red or pink exudate; thin, watery

serosanguineous

Clear or pale yellow exudate; thin, watery

serous

Bright red, fresh blood exudate

sanguineous

Dark yellow, tan, or green exudate; thick, opaque and often odorous

purulent

Drainage characteristics from small to large

none, scant, small, moderate, copious

Loss of epidermis layer of tissue only

superficial

Dermis skin layer is exposed

partial-thickness

Loss of epidermis and dermis, often involves deeper tissue layers

full-thickness

Softening and breaking down of the skin

maceration

Hardening and thickening of the skin/tissue around the wound caused by edema

induration

Total or partial separation of previously approximated edges

dehiscence

Abdominal organs protruding from surgery incision

evisceration

Tissue under the wound edge becomes eroded

undermining

Rolling/curling of wound’s edges

epibole

Intact skin, visible change in color, non-blanchable

stage 1 pressure injury

Open wound, partial-thickness skin loss, dermis is visible

stage 2 pressure injury

Open wound, full-thickness skin loss, adipose tissue is visible; granulation, slough, and eschar are common

stage 3 pressure injury

Open wound, full-thickness skin loss, deeper structures visible

stage 4 pressure injury

Osteomyelitis

infection of the bone

Full thickness skin loss, covered in slough or eschar

unstageable pressure injury

Intact skin, deep red/maroon/purple color, may feel boggy

deep tissue pressure injury

Which types of dressing are used for heavily exudating wounds?

specialty absorptive, foam, alginate

Which types of dressing are used for minimally exudating wounds?

hydrogel, hydrocolloid, occulsive

With LDA’s you should clean at least ___ down the tube

6 inches

Patients with enteral tubes should keep the head of their bed raised to at least ___ degrees

30

If a patient has less than ___ of urine output/hour, it is a problem

30mL