Untitled Flashcards Set

Pressure Ulcer Stages

Stage 1
Intact skin with non-blanchable redness, meaning the area doesn't turn white when pressed, and may feel warmer or cooler than surrounding skin.

Stage 1 - Appearance
Red or discolored skin, potentially with changes in temperature, firmness, or sensation.

Stage 1 - Symptoms
Pain, burning, or itching are common.

Stage 1 - Treatment
Focus on removing pressure, keeping the area clean and dry, and addressing any underlying causes.

Stage 2
Partial-thickness skin loss with exposed dermis, appearing as an open sore, blister, or abrasion.

Stage 2 - Appearance
The wound bed is viable, pink or red, and may be moist.

Stage 2 - Symptoms
Pain, swelling, warmth, and possible drainage or pus.

Stage 2 - Treatment
Clean with a saline solution, protect the area with moisture barriers, and address any underlying causes.

Stage 3
Full-thickness skin loss with damage to subcutaneous tissue, appearing as a crater-like wound.

Stage 3 - Appearance
The wound extends into the fat tissue, and may have a bad odor or signs of infection.

Stage 3 - Symptoms
Pain, swelling, warmth, and possible drainage or pus.

Stage 3 - Treatment
Wound care, addressing any underlying causes, and possibly surgical intervention.

Stage 4
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone.

Stage 4 - Appearance
The wound extends deeply into the tissues and may have rolled edges or eschar (hardened dead tissue).

Stage 4 - Symptoms
Extreme pain, drainage, dead tissue, and signs of infection.

Stage 4 - Treatment
Often requires surgical intervention, such as flap reconstruction, and may involve a prolonged recovery period.

Oxygen Administration for Nurses

Verify the Provider’s Order
Ensure you have a valid prescription for oxygen, including the flow rate and target oxygen saturation.

Gather Supplies
Prepare the necessary equipment, including a pulse oximeter, oxygen delivery device (nasal cannula, simple face mask, reservoir mask, Venturi mask), tubing, and humidifier (if needed).

Perform Hand Hygiene
Wash your 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 the oxygen delivery system is at least 5 feet away from heat sources.

Oxygen Safety - Check Oxygen Levels
Verify that portable oxygen tanks are adequately filled before transporting a patient.

Oxygen Safety - Ensure Oxygen Tubing is Patent
Regularly check for kinks, twists, or blockages in the tubing.

Oxygen Safety - "Oxygen in Use" Signs
Display "Oxygen in Use" signs in visible areas.

Oxygen Safety - Notify Fire Department
Inform the fire department and electric company that oxygen is being used.

Respiratory Assessment for Oxygen Therapy

Respiratory Assessment
Perform a focused respiratory assessment, including airway, respiratory rate, pulse oximetry, and lung sounds.

Oxygen Delivery Device Selection
Choose the appropriate oxygen delivery device based on the patient's condition and the prescribed oxygen concentration.

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 the oxygen tubing to the flow meter and set the oxygen flow rate as prescribed.

Ensure Proper Fit
Ensure that the oxygen delivery device fits snugly and comfortably.

Explain the Procedure
Explain the procedure to the patient and obtain their consent where possible.

Stages of Infection

Incubation Period
The pathogen enters the body and multiplies. No symptoms are present during this stage.

Prodromal Period
Early, nonspecific symptoms appear, such as fatigue, headache, or fever. The person may be contagious.

Illness Period
Full-blown symptoms develop, including specific signs of the infection (e.g., cough, rash, diarrhea). The immune system is actively fighting the pathogen.

Decline Period
Symptoms gradually improve, and the body recovers. The pathogen is being eliminated or controlled.

Convalescence Period
The body returns to its normal state. Some people may experience lingering effects or complications.

Wound Healing Terminology

Dehiscence
Partial or complete separation of outer wound layers.

Evisceration
The 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 that develops between two cavities or between an infected cavity and the skin's surface.

Common Wound Types

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 the skin with well-defined edges, usually caused by a sharp instrument; a stab wound is typically deeper than wide.

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

Patterned Wound
Wound representing the outline of the object (e.g., steering wheel) causing the wound.